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 DOBLE
NAME EXTENSION (JR., SR)
FIRST NAME CHONA FAITH

MIDDLE NAME POLOYAPOY

3. DATE OF BIRTH
(mm/dd/yyyy) 12/21/1974 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH CEBU CITY If holder of dual citizenship, Pls. indicate country: naturalization
please indicate the details.
5. SEX
Male ✘ Female
17. RESIDENTIAL ADDRESS P. DEL CORRO STREET
6 CIVIL STATUS ✘ Single House/Block/Lot No. Street
Widowed Married
Separat POBLACION 1
Other/s: ed Subdivision/Village Barangay
CARCAR CITY CEBU
7. HEIGHT (m) 4'11
City/Municipality Province
8. WEIGHT (kg) 59 KG ZIP CODE 6019

18. PERMANENT ADDRESS P. DEL CORRO STREET

9. BLOOD TYPE O+
House/Block/Lot No. Street
POBLACION 1
10. GSIS ID NO. 006012416437
Subdivision/Village Barangay
CARCAR CITY CEBU
11. PAG-IBIG ID NO. 164001629370
City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 6019

13. SSS NO. N/A 19. TELEPHONE NO. N/A

14. TIN NO. 900-774-993 20. MOBILE NO. 09606788145/09199074939

15. AGENCY EMPLOYEE NO. 2980054 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) CHONA CHRISTIE D. RETARDO
FIRST NAME N/A 10/11/2000
JESSIE ALEX D. RETARDO
MIDDLE NAME N/A 01/19/2002
MARIAN ALEXIS D. RETARDO
OCCUPATION N/A 6/10/2003
JOHN ALEXANDER D. RETARDO
EMPLOYER/BUSINESS NAME N/A 6/9/2004
NIŇA MARIE P. DOBLE
BUSINESS ADDRESS N/A 01/29/2006
RAIN FRANCIS DOBLE
TELEPHONE NO. N/A 03/13/2008
MARY EVOLET DOBLE
24. FATHER'S SURNAME DOBLE 03/30/2009
NAME EXTENSION (JR., SR) MONICA FAITH DOBLE
FIRST NAME HERNANI 2/7/2015

MIDDLE NAME ROLLON

25. MOTHER'S MAIDEN NAME

SURNAME POLOYAPOY

FIRST NAME LUZVIMINDA

MIDDLE NAME DIEZ (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST LEVEL/ SCHOLARSHIP/
26. NAME OF SCHOOL PERIOD OF ATTENDANCE YEAR
LEVEL (Write in BASIC EDUCATION/DEGREE/COURSE
(Write in full)
UNITS
GRADUATED
ACADEMIC
HONORS
full) EARNED
(if not graduated) RECEIVED
From To
1ST
ELEMENTARY SIBONGA ELEMENTARY SCHOOL GRADE 1-GRADE 6 1/6/1982 03/30/1988 N/A 1988 HONORABLE
MENTION

SECONDARY CARCAR ACADEMY GRADE 7-GRADE 10 1/6/1988 03/30/1992 N/A 1992 VALEDICTORIAN
VOCATIONAL /

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

TRADE
COURSE
COLLEGE UNIVERSITY OF SAN CARLOS BSED-FILIPINO 1/6/1992 03/30/1997 N/A 1997 N/A

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

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER RATING DATE OF
SPECIAL LAWS/ CES/ CSEE (If Applicable) EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT NUMBER Date of
Validity

PBET 78.0 AUGUST 23,1997 CEBU CITY 0262107 3/1/1998

(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
28. INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY GRADE (if STATUS OF
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To (Y/ N)

1/4/1997 12/15/1998 CLASSROOM TEACHER SISTERS OF MARY (GIRLSTOWN) 18000.00 GRADE 11 PROBITIONAL N

8/3/1999 12/30/2004 CLASSROOM TEACHER MANTALONGON NHS-DALAGUETE NHS REGULAR

GRADE 11 PERMANENT Y
EXTENSION
1/1/2005 07/28/2024 CLASSROOM TEACHER CARCAR CENTRAL NHS GRADE 11- REGULAR Y
STEP 8 PERMANENT
07/29/2024 PRESENT CLASSROOM TEACHER GELACIO C. BABAO SR. MEMORIAL NHS GRADE 11- REGULAR Y
STEP 8 PERMANENT

(Continue on separate sheet if necessary)

SIGNATURE DATE
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

N/A

N/A
(Continue on separate sheet if necessary)
VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
INCLUSIVE DATES OF
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE Type of LD
NUMBER OF HOURS
( Managerial/ CONDUCTED/ SPONSORED BY
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

IN-SERVICE TRAINING FOR TEACHERS 12-14-2020 12-15-2020 TECHNICAL CARCAR CITY DIVISION

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

COMPUTER LITERATE

SINGING

(Continue on separate sheet if necessary)

SIGNATURE DATE
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 ✘

b. within the fourth degree (for Local Government Unit - Career Employees)?
YES
✘

If YES, give details:

________________________________

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

b. Have you been criminally charged before any court? YES ✘ NO

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 any court or tribunal? YES ✘ NO
If YES, give details:
________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation,
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased YES ✘ NO
out (abolition) in the public or private sector? If YES, give details:
________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? YES ✘ NO
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last YES
election to promote/actively campaign for a national or local candidate? ✘ NO
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 specify:
If YES, please
✘ NO
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
MIGUELITA A AMISTAD LIBURON CARCAR CITY 9398957751 4.5 cm. X 3.5 cm
(passport size)
MARY GRACE BASANAL POB 1 CARCAR CITY 9606163142
Computer generated
or photocopied picture
CLEOFE A LANAS POB 1 CARCAR CITY 9363855283 is not acceptable

42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the
Philippines. I authorize the agency head/authorized representative to verify/validate the contents stated herein.
I agree that any misrepresentation made in this document and its attachments shall cause the filing of
administrative/criminal case/s against me. PHOTO

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

PLEASE INDICATE ID Number and Date of
Issuance
Government Issued ID: PRC

ID/License/Passport No.: 0262107

Signature (Sign inside the box)

Date/Place of Issuance: SEPT. 26, 2024

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