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 PORAL
NAME EXTENSION (JR., SR) N/A
FIRST NAME MARICEL

MIDDLE NAME DELA CRUZ

3. DATE OF BIRTH
(mm/dd/yyyy) 06/18/1986 16. CITIZENSHIP ✘

4. PLACE OF BIRTH BAYAWAN CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘

✘ 17. RESIDENTIAL ADDRESS

6 CIVIL STATUS
House/Block/Lot No. Street
TABUAN
Subdivision/Village Barangay
BAYAWAN NEGROS ORIENTAL
7. HEIGHT (m) 5'1
City/Municipality Province
8. WEIGHT (kg) 56 ZIP CODE
18. PERMANENT ADDRESS
9. BLOOD TYPE A+
House/Block/Lot No. Street
TABUAN
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A BAYAWAN NEGROS ORIENTAL

City/Municipality Province
12. PHILHEALTH NO. N/A ZIP CODE 6221

13. SSS NO. 34-1352383-8 19. TELEPHONE NO. N/A

14. TIN NO. N/A 20. MOBILE NO. 09750525021
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME PORAL 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) PORAL, HARRIS LANCE
FIRST NAME ROLAND N/A 08/29/2014

MIDDLE NAME HISUGAN PORAL, HARRIAH NADJMA DIANE 01/25/2022

OCCUPATION CARPENTER

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME DELA CRUZ

NAME EXTENSION (JR., SR)
FIRST NAME FELIPE

MIDDLE NAME EBOGON

25. MOTHER'S MAIDEN NAME

SURNAME CORNEL

FIRST NAME MA. PERLALUNA

MIDDLE NAME BANJOLA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
UNITS ACADEMIC
LEVEL (Write in full) EARNED
GRADUATED
HONORS
(Write in full) (if not RECEIVED
From To
graduated)
SALUTATO
ELEMENTARY BAISAN ELEMENTARY SCHOOL N/A 1992 1998 N/A 1998
RIAN
VOCATIONAL / KALUMBOYAN NATIONAL HIGH
SECONDARY
SCHOOL N/A 1998 2002 N/A 2002 N/A
TEACHER OF ENGLISH TO SPEAKER OF
OTHER LANGUAGES
N/A 2020 2020 N/A 2020 N/A
TRADE NEGROS ORIENTAL STATE BACHELOR OF SECONDARY EDUCATION -
COLLEGE
UNIVERSITY ENGLISH
2015 2019 N/A 2019 N/A
COURSE
GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)
SIGNATURE DATE July 19, 2023
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (if applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity

LICENSURE EXAMINATION FOR TEACHERS 79.8 3/27/2022 DUMAGUETE CITY 1928697 06/18/2025

(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/ SERVICE
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY PAY GRADE (if STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To
(Y/ N)
END OF
2010 2012 DOMESTIC HELPER AVD MANPOWER SERVICES 13000.00 N/A CONTRACT N

2003 2010 CASHIER SINAGTALA BAKESHOP 3500.00 N/A RESIGNED N

(Continue on separate sheet if necessary)

SIGNATURE DATE JULY 19, 2023
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (Write in
full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To
TABUAN PROVINCIAL COMMUNITY HIGH
10/16/2022 12/15/2022 320.0 TEACHER-AIDE
SCHOOL - TABUAN, BAYAWAN CITY
TABUAN PROVINCIAL COMMUNITY HIGH
1/9/2020 07/30/2022 1920.0 COMMUNITY LEARNING FACILITATOR
SCHOOL - TABUAN, BAYAWAN CITY

(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)
INCLUSIVE DATES OF
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) From To Technical/etc)

BEAUTY CARE 1/11/2020 12/30/2020 120.0 N/A ALS KALUMBOYAN

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 33.
(Write in full) (Write in
full)
SITIO BANABA MILLENIAL
ART N/A
ASSOCIATION
DRESS MAKING

HAIR DRESSER

MASSAGE

(Continue on separate sheet if necessary)

SIGNATURE DATE JULY 19, 2023

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 If YES, give details:
phased out (abolition) in the public or private sector? ________________________________
APPLYING FRO ABROAD
________________________________
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
a.
items:
Are you a member of any indigenous group? ✘
If YES, please specify:
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
the last 6 months
MRS. EMMA APDIAN BANGA, BAYAWAN CITY 09171326154 3.5 cm. X 4.5 cm
(passport size)

MRS. NELIA LADINES TABUAN, BAYAWAN CITY 09533018636 With full and handwritten
name tag and signature over
printed name
MRS. MILUNA ONGUE BANABA, BAYAWAN CITY 09973825101
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied picture
is not acceptable
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 PHOTO
filing of administrative/criminal case/s against me.

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.: 1928697

Signature (Sign inside the box)
JULY 19, 2023
Date/Place of Issuance: 06/23/2022-DUMAGUETE 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