CS Form No.

212
Revised 2017
PERSONAL DATA SHEET
WARNING: Any misinterpretation 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
. SURNAME CUIZON
NAME EXTENSION (JR., SR) N/A
FIRST NAME MARGIELEM
MIDDLE NAME GONZALES
. DATE OF BIRTH
3/10/1986 16. CITIZENSHIP
Filipino Dual Citizenship
(mm/dd/yyyy) ✘ by
by
birt
naturalization
. PLACE OF BIRTH
BALAGONON MANAGA BANSALAN If holder of dual citizenship,
h
Pls. indicate country:
DAVAO DEL SUR
please indicate the details.
. SEX Male ✘ Female
✘
### CIVIL STATUS Single 17. RESIDENTIAL ADDRESS
Married N/A N/A
Wido Separat
Other/
wed ed
Purok CAMANCHILES SAN JOSE BALUTAKAY
s: Subdivision/Village Barangay

Digos City Davao del Sur

. HEIGHT (m) 147m
City/Municipality Province

. WEIGHT (kg) 50KG ZIP CODE 8002

18. PERMANENT ADDRESS N/A
9.BLOOD TYPE O
House/Block/Lot No. Street

10.GSIS ID NO. N/A Camanchiles San Jose

Subdivision/Village Barangay

11.PAG-IBIG ID NO. N/A Digos City Davao del Sur

City/Municipality Province

. PHILHEALTH NO. 16-025427533-3 ZIP CODE 8002

. SSS NO. 0111-1751982-3 19. TELEPHONE NO. N/A

14. TIN NO. 489-448-901-000 20. MOBILE NO. 09121989908

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
2SPOUSE'S SURNAME CUIZON 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME
NAME EXTENSION (JR., SR) N/A SICILIAN KATE G. CUIZON 12/06/2009
VELJUN
MIDDLE NAME MONTECILLO EWFIM G. CUIZON 08/31/2013

OCCUPATION TEACHER-I CHESSICA G. CUIZON 08/26/2015

EMPLOYER/BUSINESS NAME SOONG NATIONAL HIGH SCHOOL DHEYCOV G. CUIZON 06/26/2021

BUSINESS ADDRESS SOONG DIGOS CITY

TELEPHONE NO. 9477474608

24.FATHER'S SURNAME GONZALES

FIRST NAME LEMY SR.

MIDDLE NAME SITON

2MOTHER'S MAIDEN NAME

SURNAME TAGALOG

FIRST NAME MARIA

MIDDLE NAME PROCORATO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL BASIC HIGHEST LEVEL/

26. EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE
UNITS
YEAR
SCHOLARSHIP/ ACADEMIC
LEVEL (Write in GRADUAT HONORS RECEIVED
(Write in full) EARNED
full) ED
(if not graduated)
From To

ELEMENTARY IGPIT DIGOS CITY ELEMENTARY EDUCATION 1999 2000 GRADUATED 2000 With Merit

SECONDARY
DAVAO DEL SUR NATIONAL HIGH SECONDARY EDUCATION 2001 2005 GRADUATED 2005 N/A
SCHOOL
Asian Institute of Technology Digos Beauty care and Services 7/02/2017 8/28/2023 passed N/A TESDa
VOCATIONAL / City Nail Care
TRADE COURSE Philippine College of Technology COMPUTER DATA 06/2005 10/2005 passed
Bajada Davao City ENCODER

COLLEGE
SOUTHEASTERN COLLEGE OF BACHELOR OF SECONDARY
2019 2020 GRADUATED 2020 UNIFAST
PADADA EDUCATION MAJOR IN FILIPINO

GRADUATE STUDIES
Rizal Memorial Colleges, Inc. Davao MAT-FIL 2023 Present 9 UNITS N/A N/A
City
(Continue on separate sheet if necessary)

SIGNATURE DATE 04222024 CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY
27. LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL RATING DATE OF
LAWS/ CES/ CSEE BARANGAY (If Applicable) EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
ELIGIBILITY / DRIVER'S LICENSE CONFERMENT NUMBER Date of
Validity

LICENSURE EXAMINATION FOR TEACHERS (LET) 83 03/26/2022 ATTENIO DE DAVAO CITY 1912082 03/10/2025

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

01/01/2023 06/31/2023 DiCNHS-SAN ROQUE EXTENTION CONTRACTUAL

LOCAL SCHOOL BOARD TEACHER 7,000 N/A
01/08/2022 12/31/2022 LOCAL SCHOOL BOARD TEACHER DiCNHS-SAN ROQUE EXTENTION 5000 CONTRACTUAL N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 04/22/2024 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 NUMBER OF
(Write in full) (mm/dd/yyyy) 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)

TITLE OF LEARNING AND DEVELOPMENT INCLUSIVE DATES OF ATTENDANCE Type of LD

NUMBER OF
30. INTERVENTIONS/TRAINING PROGRAMS (Write in HOURS ( Managerial/ Supervisory/ CONDUCTED/ SPONSORED BY (Write in full)
full) (mm/dd/yyyy) Technical/etc)

MiD-YEAR PERFORMANCE REVIEW AND EVALUATION(MPRE) 02/06/2023 02/10/2023 40HRS TECHNICAL DIGOS CITY NATIONAL HIGH SCHOOL

TESOL 4/14/2023 4/29/2023 120 TECHNICAL

GLEARS INTERNATIONAL RESEARCH CERTIFICATE

Pampaaralang Pagsasanay sa Ortograpiyang Pambansa 02/8/2023 02/8/2023 8 HRS. TECHNICAL DIGOS CITY NATIONAL HIGH SCHOOL

POLICY GUIDELINES ON CLASSROOM ASSESSMENTFOR K-12 BASIC

EDUCATION PROGRAM
3/10/2023 3/10/2023 8HRS TECHNICAL DIGOS CITY NATIONAL HIGH SCHOOL

ORIENTATION ON THE NEW CLASSROOM OBSERVATION(COT) 3/10/2023 3/10/2023 8HRS TECHNICAL DIGOS CITY NATIONAL HIGH SCHOOL

PHILIPPINE COLLEGE OF TECHNOLOGY

COMPUTER DATA ENCODR 6/15/2005 10/30/2005 80HRS TECHNICAL BAJADA DAVAO CITY

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

PLAYING CHESS N/A N/A

READING STORIES N/A N/A

COOKING N/A N/A

COMPUTER LITERATE N/A N/A

SIGNATURE DATE CS FORM 212 (Revised 2017), Page 3 of 4

4/22/2024
 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? ✘ NO
YES
b. within the fourth degree (for Local Government Unit - Career Employees)? ✘NO
YES
If YES, give details:
________________________________

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

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

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

39. Have you acquired the status of an immigrant or permanent resident of another country?
✘ NO
YES
If YES, give details (country):

40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA
a. 7277);
Are youand (c) SoloofParents
a member Welfare Act
any indigenous of 2000 (RA 8972), please answer the following items:
group? ✘ NO
If YES,YES
please specify:
b. Are you a person with disability? ✘ NO
If YES,YES
please specify ID No:
c. Are you a solo parent? ✘ NO
If YES,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
MR. ALAN B. TIZON DEL PILAR ST. DIGOS CITY 9815266962 the last 6 months
3.5 cm. X 4.5 cm
(passport size)
ROTSHEN V. CASILAC LUNA EXT. DIGOS CITY 9630 652244
With full and handwritten
AIMEE AMOR PORTO MATTI DIGOS CITY 9562442886 name tag and signature over
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete printed name
statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. I
Computer generated
authorize the agency head / authorized representative to verify/validate the contents stated herein. I agree that any or photocopied picture
misrepresentation made in this document and its attachments shall cause the filing of administrative/criminal case/s is not acceptable
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: PROFESSIONAL REGULATION

COMMISSION

ID/License/Passport No.: 1912082

Signature (Sign inside the box)
09/25/2023
Date/Place of Issuance: 05/17/2022/DAVAO 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