CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misrepresentation made in the Personal Data Sheet and the Work Experience Sheet shall cause the filing of administrative/criminal case/s against the person
concerned.
READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.
Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE. 1. CS ID No. (Do not fill up. For CSC use only)

I. PERSONAL INFORMATION
2. SURNAME DELA CERNA

FIRST NAME ALLAN NAME EXTENSION (JR., SR) JR

MIDDLE NAME NALLOS

3. DATE OF BIRTH
(mm/dd/yyyy)
08/08/1999 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH GENERAL SANTOS CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

Single ✘ Married 17. RESIDENTIAL ADDRESS BLOCK 9 ZONE 3

6 CIVIL STATUS
Separated House/Block/Lot No. Street
Widowed N/A FATIMA
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 1.65 m GENERAL SANTOS CITY SOUTH COTABATO
City/Municipality Province
8. WEIGHT (kg) 63 kg ZIP CODE 9500
18. PERMANENT ADDRESS BLOCK 9 ZONE 3
9. BLOOD TYPE O+ House/Block/Lot No. Street
N/A FATIMA
10. GSIS ID NO. N/A Subdivision/Village Barangay
GENERAL SANTOS CITY SOUTH COTABATO
11. PAG-IBIG ID NO. N/A City/Municipality Province
12. PHILHEALTH NO. 17-250812900-4 ZIP CODE 9500

13. SSS NO. 34-9562583-5 19. TELEPHONE NO. 083-826-0216

14. TIN NO. 624-442-937 20. MOBILE NO. 09198158695

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME DELA CERNA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME MESARAH

NAME EXTENSION (JR., SR) N/A CIRILLA ZAFREEN DELA CERNA 01/24/2022

MIDDLE NAME KALANTUNGAN

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS BARANGAY FATIMA, GENERAL SANTOS CITY

TELEPHONE NO. 9213211840
24. FATHER'S SURNAME DELA CERNA

FIRST NAME ALLAN NAME EXTENSION (JR., SR) SR.

MIDDLE NAME LUMOGDANG

25. MOTHER'S MAIDEN NAME

SURNAME NALLOS

FIRST NAME MARY ANN

MIDDLE NAME BACULNA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL HIGHEST LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
BASIC EDUCATION/DEGREE/COURSE UNITS ACADEMIC
LEVEL (Write in EARNED
GRADUATED
(Write in full) HONORS
full) (if not graduated) RECEIVED
From To

SAMPAGUITA EDUCATIONAL
ELEMENTARY ELEMENTARY 2006 2011 N/A 2011 N/A
INSTITUTE

VOCATIONAL GENERAL SANTOS CITY NATIONAL

SECONDARY / HIGH SCHOOL 2011 2015 N/A 2015 N/A
HIGHSCHOOL

N/A N/A N/A N/A N/A N/A N/A

TRADE
BACHELOR OF ELEMENTARY
COURSE
COLLEGE MINDANAO STATE UNIVERSITY 2015 2019 N/A 2019 N/A
EDUCATION

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A

POST GRADUATE N/A N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 03/08/2023 CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER LICENSE (if applicable)
RATING DATE OF
SPECIAL LAWS/ CES/ CSEE
(If EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY / DRIVER'S NUMBER Date of
Applicable) CONFERMENT
LICENSE Validity
LICENSURE EXAMINATION FOR
82.6% 9/29/2019 GENERAL SANTOS CITY 1859618 8/8/2023
TEACHERS

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experience sheet.
GOV'T SERVICE
28. INCLUSIVE DATES POSITION TITLE SALARY/ JOB/
(mm/dd/yyyy) PAY GRADE (if
DEPARTMENT / AGENCY / OFFICE / COMPANY STATUS OF
MONTHLY SALARY applicable)& STEP
(Write in (Write in full/Do not abbreviate) (Format "00-0")/ APPOINTMENT
From To full/Do not abbreviate) INCREMENT
(Y/ N)

08/15/2020 02/15/2023 Graphic Designer T & I KUSTOMAYZ PRINTS ₱ 9,600.00 N/A N/A N/A

DADIANGAS WEST CENTRAL ELEMENTARY

03/15/2023 6/15/2023 Substitute Teacher ₱ 27,000.00
SCHOOL

(Continue on separate sheet if necessary)

SIGNATURE DATE 03/08/2023 CS FORM 212 (Revised 2017), Page 2 of 4

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
29. NAME & ADDRESS OF ORGANIZATION
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED

(Start from the most recent L&D/training program and include only the relevant L&D/training taken for the last five (5) years for Division Chief/Executive/Managerial positions)

INCLUSIVE DATES OF ATTENDANCE

30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS Type of LD
CONDUCTED/ SPONSORED BY
(mm/dd/yyyy) NUMBER OF HOURS ( Managerial/ Supervisory/
(Write in full) Technical/etc) (Write in full)

From To

1st International Computer

12/05/2021 12/15/2021 240 TECHNICAL
Technology Colleges Incorporated
Basic Computer Literacy

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)
(Write in full)

GRAPHIC DESIGNING N/A N/A

VIDEO EDITING N/A N/A

WELDING N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 03/08/2023 CS FORM 212 (Revised 2017), Page 3 of 4

 34. Are you related by consanguinity or affinity to the appointing or recommending authority, or to the
chief of bureau or office or to the person who has immediate supervision over you in the Office,
Bureau or Department where you will be apppointed,
a. within the third degree? YES ✘ NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES NO
If YES, give details: ________________________________
________________________________

35. a. Have you ever been found guilty of any administrative offense? YES ✘ NO
If YES, give details: ________________________________
________________________________

YES ✘ NO
b. Have you been criminally charged before any court?
If YES, give details: ________________________________
________________________________
Date Filed:
Status of Case/s:

36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by NO
YES ✘
any court or tribunal?
If YES, give details: ________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation, retirement, YES ✘ NO
dropped from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) If YES, give details: ________________________________
in the public or private sector? ________________________________

38. a. Have you ever been a candidate in a national or local election held within the last year (except
YES ✘ NO
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last YES ✘ NO
election to promote/actively campaign for a national or local candidate? If YES, give details:

39. Have you acquired the status of an immigrant or permanent resident of another country?
YES ✘ NO
If YES, give details (country):
40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA 7277);
and (c) Solo Parents Welfare Act of 2000 (RA 8972), please answer the following items:

a. Are you a member of any indigenous group? YES ✘ NO

If YES, please specify:
b. Are you a person with disability? YES ✘ NO
If YES, please specify ID No:
c. Are you a solo parent? YES ✘ NO
If YES, please specify ID No:

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAME ADDRESS TEL. NO. ID picture taken

within
the last 6 months
DANTE P. CUADRADO MABUHAY, GENERAL SANTOS CITY 9163647564 3.5 cm. X 4.5 cm
(passport size)
JETZLE B. ALPUERTO FATIMA, GENERAL SANTOS CITY 9606472737
With full and
ROLANDO S. MADEJA FATIMA, GENERAL SANTOS CITY 9692736085 handwritten
name tag and
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete statement signature over
pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. I authorize the agency head / printed name
authorized representative to verify/validate the contents stated herein. I agree that any misrepresentation made in this document
Computer
and its attachments shall cause the filing of administrative/criminal case/s against me. generated
PHOTO
or photocopied
picture
is not acceptable

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License,

etc.)PLEASE INDICATE ID Number and Date of Issuance
PROFESSIONAL REGULATION
Government Issued ID: COMMISSION

ID/License/Passport No.: 1859618 Signature (Sign inside the box)

03-08-2023
Date/Place of Issuance: 01/22/2020/GENERAL SANTOS CITY
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this ,affiant exhibiting his/her validly issued government ID as indicated above.

Person Administering Oath

CS FORM 212 (Revised 2017), Page 4 of 4