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 GOMEZ
NAME EXTENSION (JR., SR)
FIRST NAME CHRISTINE JOY

MIDDLE NAME GANADE

3. DATE OF BIRTH
(mm/dd/yyyy) 9/14/1999 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH BUTUAN CITY, AGUSAN DEL NORTE If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Female
Male ✘

Single
17. RESIDENTIAL ADDRESS PUROK 1
6 CIVIL STATUS ✘ Married
House/Block/Lot No. Street
Widowed Separate
d
BAN-AS
Other/s:
Subdivision/Village Barangay

7. HEIGHT (m) 1.53m LIANGA SURIGAO DEL SUR

City/Municipality Province
8. WEIGHT (kg) 50kg ZIP CODE 8307

9. BLOOD TYPE O 18. PERMANENT ADDRESS PUROK 1

House/Block/Lot No. Street

10. GSIS ID NO. N/A BAN-AS

Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A LIANGA SURIGAO DEL SUR

City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 8307

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

14. TIN NO. N/A 20. MOBILE NO. 09382445804

15. AGENCY EMPLOYEE NO. N/A 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)
FIRST NAME N/A N/A N/A

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME GOMEZ

NAME EXTENSION (JR., SR)
FIRST NAME RODERICK

MIDDLE NAME CAVERTE

25. MOTHER'S MAIDEN NAME

SURNAME GANADE

FIRST NAME MARICHU

MIDDLE NAME LAMADORA (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

ELEMENTARY BAN-AS ELEMENTARY SCHOOL PRIMARY EDUCATION 7/6/2004 8/4/2011 DIPLOMA 2011 DIPLOMA

SECONDARY
LIANGA NATIONAL COMPREHENSIVE HIGH SCHOOL 7/6/2011 3/21/2015 DIPLOMA 2015 DIPLOMA
VOCATIONAL / HIGH SCHOOL

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

TRADE
COURSE
COLLEGE SURIGAO DEL SUR STATE UNIVERSITY BACHELOR OF ELEMENTARY 8/6/2015 5/4/2019 DIPLOMA 2019 DIPLOMA
EDUCATION

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

(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 26, 2024

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

LICENSURE EXAMINATIONS FOR TEACHERS 88.4 1/30//2022 BUTUAN CITY, AGUSAN DEL NORTE 1911914 9/14/2025

(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)

1/9/2022 2/28/2023 VOLUNTEER TEACHER BAN-AS ELEMENTARY SCHOOL N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 26, 2024

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
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

NATIONAL CERTIFICATE II IN ORGANIC AGRICULTURE PRODUCTION 3/4/2022 4/13/2022 88.0 TECHNICAL EDFHER FARM AGRICULTURAL LEARNING
SCHOOL

(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)

N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 26, 2024

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 ✘ 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
MARICEL A. ARNIGO DIATAGON, LIANGA, SDS 9079850168 4.5 cm. X 3.5 cm
(passport size)
JULITO T. MANGADLAO ST. CHRISTINE, LIANGA, SDS 9074111460
Computer generated
or photocopied picture
ULDARICO B. LUAREZ LIANGA, SDS 9383760691 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

ID/License/Passport No.: 1911914 Signature (Sign inside the box)

APRIL 26, 2024
Date/Place of Issuance: 5/17/2022 - BUTUAN 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