PDS 1

CS FORM 212 (Revised 2005)
PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes
with "
1. CS ID No.
" and use separate sheet if necessary.
(to be filled up by CSC)
1. PERSONAL INFORMATION
FIRST NAME
MIDDLE NAME
2. SURNAME
Mayuga, Libagon, Southern Leyte
Kawayan, Libagon, Southern Leyte
6. SEX
Male
7. CIVIL STATUS
Single
Widowed
Married
Separated
17. TELEPHONE NO.
Others, (specify)____
18. PERMANENT ADDRESS
Annulled
8. CITIZENSHIP
Filipino
9. HEIGHT (m)
1.73 m.
None
3. NAME EXTENSION (e.g. Jr., Sr.)

16. RESIDENTIAL ADDRESS
05/02/1987
4. DATE OF BIRTH (mm/dd/yyyy)

5. PLACE OF BIRTH
Female
ZIP CODE
6615
NONE
10. WEIGHT (kg)
60 kg.
11. BLOOD TYPE
19. TELEPHONE NO.
NONE
12. GSIS ID NO.
2004534409
20. E-MAIL ADDRESS (if any)
[email protected]
13. PAG-IBIG ID NO.
NONE
21. CELLPHONE NO. (if any)
09265222820
14. PHILHEALTH NO.
13-050106965-6
22. AGENCY EMPLOYEE NO.
15. SSS NO.
0629493276
23. TIN
ZIP CODE
6615
287-754-607
II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME
NONE
25. NAME OF CHILD (Write full name and list all)
DATE OF BIRTH (mm/dd/yyyy)
NONE
OCCUPATION
EMPLOYER/BUS. NAME
BUSINESS ADDRESS
TELEPHONE NO.
FIRST NAME
Guzman
Carlos
MIDDLE NAME
Oblima
FIRST NAME
MIDDLE NAME
(Continue on separate sheet if necessary)

26. FATHER'S SURNAME
27. MOTHER'S MAIDEN NAME

SURNAME
Calibo
FIRST NAME
Juliana
MIDDLE NAME
Ampong
III. EDUCATIONAL BACKGROUND

28.
YEAR
GRADUATED
NAME OF SCHOOL
LEVEL
(Write in
DEGREE COURSE
(Write in full)
full)
(if
HIGHEST GRADE/
LEVEL/
UNITS EARNED
(if not graduated)
INCLUSIVE DATES OF
ATTENDANCE
From
To
SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED
graduated)
ELEMENTARY
Kawayan Elementary School
Elementary
2000
Graduated
1993
2000
First Honor
SECONDARY
VOCATIONAL /
Libagon Academy
Seconary
2004
Graduated
2000
2004
4TH Honorable
Mention
Graduated
2005
2009
Cum Laude
NONE
TRADE
COURSE
COLLEGE
Southern Leyte State University Tomas Oppus
BSED-Math
2009
GRADUATE STUDIES

Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY

29.
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER

SPECIAL LAWS/ CES/ CSEE
RATING
Civil Service Eligibility (Honor Graduate)
Licensure Examination for Teachers
77.2
LICENSE (if applicable)
DATE OF
EXAMINATION /
CONFERMENT
PLACE OF EXAMINATION / CONFERMENT
03/31/2009
10/04/2009
NUMBER
DATE OF
RELEASE
Tomas Oppus, Southern Leyte
10080145
3/24/2009
Tacloban City
1048123
02/23/2010
V. WORK EXPERIENCE (Include private employment. Start from your current work)
INCLUSIVE DATES
(mm/dd/yyyy)
30.
From
DEPARTMENT / AGENCY / OFFICE / COMPANY

(Write in full)
To
08/24/2009
POSITION TITLE
(Write in full)
GOV'T
SERVICE
MONTHLY
SALARY
SALARY GRADE &

STEP INCREMENT
(Format "00-0")
STATUS OF
APPOINTMENT
(Yes /
03/31/2014
Classroom Teacher
Libagon Academy Foundation, Inc.
No)

CS FORM 212 (Revised 2005), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

INCLUSIVE DATES
31. NAME & ADDRESS OF ORGANIZATION
NUMBER OF
HOURS
(mm/dd/yyyy)
(Write in full)
From
POSITION / NATURE OF WORK
To
VII. TRAINING PROGRAMS (Start from the most recent training.)

INCLUSIVE DATES OF ATTENDANCE
32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write
in full)
(mm/dd/yyyy)
NUMBER OF
HOURS
CONDUCTED/ SPONSORED BY
(Write in full)
From
To
Senor High School Orientation
10/29/2014
10/30/1014
16 hours
DepEd-Southern Leyte
Teachers' Induction Program
08/15/2014
08/17/2014
24 hours
Training-Workshop on the New School Improvement

Plan
07/02/2014
07/04/2014
24 hours
Basic Application Software
03/31/2014
04/04/2014
40 hours
03/01/2013
03/01/2013
11/27/2013
11/29/2013
24 hours
Libagon District
04/17/2013
04/19/2013
24 hours
Fund Assistance for Private

Education
04/26/2013
04/26/2013
8 hours
Plan, Department of Education
05/28/2012
05/30/2012
24 hours

Education
Seminar on Statistical Data Analysis Using SPSS
10/15/2013
10/15/2013
8 hours
SLSU-Main Campus
5TH Diocesan Educator's Congress
03/10/2012
03/10/2012
8 hours
Catholic Educational
Association of the Philippines
Instructional Updating Seminar
01/10/2011
01/10/2011
8 hours
Salesiana Books
02/26/2011
02/26/2011
8 hours
2011 In-Servive Training on the Secondary Education

Curriculum
05/26/2011
05/29/2011
24 hours

Education
Seminar Workshop on Leadership
02/27/2010
02/27/2010
8 hours
Phoenix Publishing House, Inc.
Seminar Workshop on the Preparation for the National

Achievement Test
01/09/2010
01/09/2010
8 hours
Eastern Visayas Association of

the Philippines

Basic Computer Literacy Training
2013 In-Service Training for Grade 8 Teachers
Orientation of Teachers in the DepEd's Child Protection
Policy
2012 In-Service Training for Grade 7 Teachers
Villa Jacinta National Vocational

High School
8 hours
VIII. OTHER INFORMATION

33.
SPECIAL SKILLS / HOBBIES:
NON-ACADEMIC DISTINCTIONS / RECOGNITION:

34.
(Write in full)
35.
MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(Write in full)
Computer Literate

36. Are you related by consanguinity or affinity to any of the following :
YES NO
a. Within the third degree (for National Government Employees):
appointing authority, recommending authority, chief of office/bureau/department or person who

has immediate supervision over you in the Office, Bureau or Department where you will be
appointed?
If YES, give details:

_____________________________________
_____________________________________
_____________________________________
YES NO
b. Within the fourth degree (for Local Government Employees):
appointing authority or recommending authority where you will be appointed?

_____________________________________
_____________________________________
_____________________________________
37 a. Have you ever been formally charged?
YES NO

________________________________
________________________________
YES NO
b. Have you ever been guilty of any administrative offense?

________________________________
________________________________
38. Have you ever been convicted of any crime or violation of any law, decree, ordinance or
regulation by any court or tribunal?
YES NO
________________________________
________________________________
39. 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, AWOL or
phased out, in the public or private sector?
40. Have you ever been a candidate in a national or local election (except Barangay election)?
YES NO
________________________________
________________________________
YES NO
________________________________
________________________________
41. 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.
YES NO
Are you a member of any indigenous group?
If YES, please specify: ____________________

b.
YES NO
Are you differently abled?

c.
YES NO
Are you a solo parent?

42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)
NAME
ADDRESS
Hon. Mayor Oliver E. Ranque
Tigbao, Libagon, Southern Leyte
Hon. Brgy. Captain Emelito T. Amparo
Lourdes E. Castil
Jubas, Libagon, Southern Leyte
TEL. NO.
43. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the
Philippines.
I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust
that this information shall remain confidential.
ID picture taken within

the last 6 months
3.5 cm. X 4.5 cm
(passport size)
Computer generated
or xerox copy of picture
is not acceptable
PHOTO
23014862
COMMUNITY TAX CERTIFICATE NO.
Libagon, Southern Leyte

ISSUED AT
SIGNATURE (Sign inside the box)
01/08/2015
03/30/2015
ISSUED ON (mm/dd/yyyy)
DATE ACCOMPLISHED
RIGHT THUMBMARK

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CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

" and use separate sheet if necessary.

(to be filled up by CSC)

Mayuga, Libagon, Southern Leyte

Kawayan, Libagon, Southern Leyte

17. TELEPHONE NO.

18. PERMANENT ADDRESS

3. NAME EXTENSION (e.g. Jr., Sr.)

4. DATE OF BIRTH (mm/dd/yyyy)

10. WEIGHT (kg)

11. BLOOD TYPE

19. TELEPHONE NO.

12. GSIS ID NO.

20. E-MAIL ADDRESS (if any)

13. PAG-IBIG ID NO.

21. CELLPHONE NO. (if any)

14. PHILHEALTH NO.

22. AGENCY EMPLOYEE NO.

15. SSS NO.

II. FAMILY BACKGROUND

25. NAME OF CHILD (Write full name and list all)

DATE OF BIRTH (mm/dd/yyyy)

(Continue on separate sheet if necessary)

27. MOTHER'S MAIDEN NAME

(Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

Kawayan Elementary School

Southern Leyte State University Tomas Oppus

(Continue on separate sheet if necessary)

IV. CIVIL SERVICE ELIGIBILITY

CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER

Civil Service Eligibility (Honor Graduate)

Licensure Examination for Teachers

LICENSE (if applicable)

PLACE OF EXAMINATION / CONFERMENT

Tomas Oppus, Southern Leyte

(Continue on separate sheet if necessary)

DEPARTMENT / AGENCY / OFFICE / COMPANY

SALARY GRADE &

Libagon Academy Foundation, Inc.

(Continue on separate sheet if necessary)

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

(Continue on separate sheet if necessary)

VII. TRAINING PROGRAMS (Start from the most recent training.)

Senor High School Orientation

Teachers' Induction Program

Training-Workshop on the New School Improvement

Basic Application Software

Fund Assistance for Private

Plan, Department of Education

Fund Assistance for Private

Seminar on Statistical Data Analysis Using SPSS

5TH Diocesan Educator's Congress

Instructional Updating Seminar

4TH Diocesan Educator's Congress

2011 In-Servive Training on the Secondary Education

Fund Assistance for Private

Seminar Workshop on Leadership

Phoenix Publishing House, Inc.

Seminar Workshop on the Preparation for the National