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 TRAZONA
NAME EXTENSION (JR., SR)
FIRST NAME KHAREN

MIDDLE NAME PLAZA

3. DATE OF BIRTH
(mm/dd/yyyy) 4/11/1991 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH BUNAWAN If holder of dual citizenship, Pls. indicate country: naturalization
please indicate the details.
5. SEX
Male ✘ Female
17. RESIDENTIAL ADDRESS P-2
6 CIVIL STATUS
Single ✘ Married House/Block/Lot No. Street
Widowed Separat COALICION
Other/s: ed Subdivision/Village Barangay
SAN LUIS AGUSAN DEL SUR
7. HEIGHT (m) 1.57
City/Municipality Province
8. WEIGHT (kg) 65 ZIP CODE 8511

18. PERMANENT ADDRESS P-2

9. BLOOD TYPE 0
House/Block/Lot No. Street
COALICION
10. GSIS ID NO. 2004590747
Subdivision/Village Barangay
SAN LUIS AGUSAN DEL SUR
11. PAG-IBIG ID NO. 121131859507
City/Municipality Province

12. PHILHEALTH NO. 180000584477 ZIP CODE 8511

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 454-463-256 20. MOBILE NO. 09073598341

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) KEN JARHEN P. TRAZONA
FIRST NAME 06/28/2015
NEIL JOSEPH P. TRAZONA
MIDDLE NAME 03/28/2017
JE CARL P. SALUDO
OCCUPATION 02/17/2024

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME PLAZA

NAME EXTENSION (JR., SR)
FIRST NAME ASTERIO

MIDDLE NAME PENALOGA

25. MOTHER'S MAIDEN NAME

SURNAME BARTONICO

FIRST NAME CHARLITA

MIDDLE NAME CALISAS (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 EAST BUNAWAN CENTRAL ELEMENTARY SCHOOL 06/17/2000 04/22/2004 2004

SECONDARY BUNAWAN NATIONAL HIGH SCHOOL 06/18/2004 04/18/2008 2008

VOCATIONAL /

TRADE
COURSE AGUSAN SUR STATE COLLEGE OF AGRICULTURE
COLLEGE AND TECHNOLOGY 06/21/2008 12/4/2012 2012

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE 01/14/2025

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 Examination for Teachers 84.0 09/27/2012 Davao City 1188097 4/11/2027

(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)

10/11/2012 06/14/2013 LOCAL PAID TEACHER SAN ROQUE NATIONAL HIGH SCHOOL 7000.00 LOCAL YES

06/20/2013 08/21/2013 SUBSTITIUTE TEACHER SINOBONG NATIONAL HIGH SCHOOL 19000.00 11 SUBSTITUTE YES

05/21/2014 PRESENT PERMANENT TEACHER SAN LUIS NATIONAL HIGH SCHOOL 30000.00 11 STEP 4 PERMANENT YES

(Continue on separate sheet if necessary)

SIGNATURE DATE 01/14/2025

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

(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
MUNICIPAL CAPACITY BUILDING ON MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT 11/21/2024 11/22/2024 16.0 SAN LUIS DISTRICT I
SERVICES

DIVISION SCIENCE AND TECHNOLOGY TRAINING FAIR FOR SCIENCE TEACHERS 8/12/2024 11/12/2024 24.0 DIVISION OF AGUSAN DEL SUR

(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)

CHILD PROTECTION POLICY LOGO MAKING CONTEST CHAMPION (TEACHERS ADVISER- YOUTH FOR ENVIRONMENT IN
CATEGORY) SCHOOLS ORGANIZATION
DELTA FRATERNITY AND SORORITY
INTERNATIONAL

(Continue on separate sheet if necessary)

SIGNATURE DATE 01/14/2025

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
REANTO T. CORPORAL LAMINGA, DON ALEJANDRO, SAN LUIS, the last 6 months
AGUSAN DEL SUR 926441204 4.5 cm. X 3.5 cm
(passport size)

Computer generated
or photocopied picture
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.: 1188097

Signature (Sign inside the box)

Date/Place of Issuance: 11/04/2024

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