CS Form No.

212
Revised 2017
PERSONAL DATA SHEET
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

RA 1080 (LICENSE PROFESSIONAL TEACHERS) 81.2 03/19/2023 LAGAO CENTRAL ELEMENTARY SCHOOL 2114134 6/27/24219

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

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

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

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

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

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

(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)

1/9/2023 PRESENT COLLEGE INSTRUCTOR SANTA CRUZ MISSION SCHOOL, INC. 10000.00 SG 1 CONTRATUAL NO

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(Continue on separate sheet if necessary)

SIGNATURE DATE DECEMBER 17, 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 NA NA NA NA

N/A NA NA NA NA

N/A NA NA NA NA

N/A NA NA NA NA

N/A NA NA NA NA

N/A NA NA NA NA

N/A NA NA NA NA
(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

N/A N/A NA N/A N/A NA

N/A N/A NA N/A N/A NA

N/A N/A NA N/A N/A NA

N/A N/A NA N/A N/A NA

N/A N/A NA N/A N/A NA

N/A N/A NA N/A N/A NA

N/A N/A NA N/A N/A NA

N/A N/A NA N/A N/A NA

N/A N/A NA N/A N/A NA

N/A N/A NA N/A N/A NA

N/A N/A NA N/A N/A NA

N/A N/A NA N/A N/A NA

N/A N/A NA N/A N/A NA

N/A N/A NA N/A N/A NA

N/A N/A NA N/A N/A NA

N/A N/A NA N/A N/A NA

N/A N/A NA N/A N/A NA

N/A N/A NA N/A N/A NA

N/A N/A NA N/A N/A NA

N/A N/A NA N/A N/A NA

N/A N/A NA N/A N/A NA

(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 (Microsoft World, Excel PASSER LICENSURE EXAMINATION FOR PROFESSIONAL TEACHER MINDANAO STATE UNIVERSITY GENSAN
and Power Point) ALUMNI

ORGANIZING MINDANAO STATE UNIVERSITY GENSAN

KABPAPAGARIYA ENSEMBLE ALUMNI

GOOD COMMUNICATION SKILLS

(Continue on separate sheet if necessary)

SIGNATURE DATE DECEMBER 17, 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? ✘

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

If YES, give details:

________________________________

35. a. Have you ever been found guilty of any administrative offense?
✘

If YES, give details:

________________________________
________________________________

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 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, dropped from the rolls, dismissal, termination, end of term, finished contract or phased If YES, give details:
out (abolition) 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
Barangay election)? ✘

If YES, give details:

b. Have you resigned from the government service during the three (3)-month period before the last ✘
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?
✘
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?
✘
If YES, please specify: T'BOLI
b. Are you a person with disability? ✘
If YES, please specify ID No:
c. Are you a solo parent? ✘
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
MARIVIC M. BEN LAMDALAG LAKE SEBU SOUTH the last 6 months
COTABATO 09456600571 4.5 cm. X 3.5 cm
(passport size)
RUSSEL L. TANAEL POBLACION LAKE SEBU SOUTH
COTABATO 09090738584
Computer generated
or photocopied picture
VIA CRIZEL O. SILAW KLUBI LAKE SEBU SOUTH COTABATO 09557113477 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.: 2114134

Signature (Sign inside the box)
DECEMBER 17, 2024
Date/Place of Issuance: 09/22/2023-PRC KORONADAL 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