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 PABLO
NAME EXTENSION (JR., SR)
FIRST NAME ELOICE

MIDDLE NAME DELA CRUZ

3. DATE OF BIRTH
12/18/1992 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH MANALUYONG CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female
Single 17. RESIDENTIAL ADDRESS Lacuna Street
6 CIVIL STATUS ✘ Married
House/Block/Lot No. Street
Widowed Separate Poblacion I
Other/s: d Subdivision/Village Barangay
7. HEIGHT (m) 170.18 cm Peñaranda Nueva Ecija
City/Municipality Province
8. WEIGHT (kg) 53 KG ZIP CODE 3103

9. BLOOD TYPE
18. PERMANENT ADDRESS Lacuna Street
House/Block/Lot No. Street

10. GSIS ID NO.

Poblacion I
Subdivision/Village Barangay
Peñaranda Nueva Ecija
11. PAG-IBIG ID NO. 1212-0144-7607
City/Municipality Province

12. PHILHEALTH NO. 21-200307446-0 ZIP CODE 3103

13. SSS NO. 02-4216026-1 19. TELEPHONE NO.

14. TIN NO. 337-952-258-000 20. MOBILE NO. 0926-967-9454

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) cadence1892@yahoo.com
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)
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME PABLO

NAME EXTENSION (JR., SR)
FIRST NAME PABLITO

MIDDLE NAME PASCUAL

25. MOTHER'S MAIDEN NAME

SURNAME DELA CRUZ

FIRST NAME ZOILA

MIDDLE NAME CARAIG (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL HIGHEST LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
BASIC EDUCATION/DEGREE/COURSE UNITS ACADEMIC
LEVEL (Write in EARNED
GRADUATED
HONORS
(Write in full)
full) (if not graduated) RECEIVED
From To

VALEDICTORIA
ELEMENTARY ILAYA BARANGKA ELEMENTARY SCHOOL 6/1/2002 3/27/2008 2008 N

VALEDICTORIA
SECONDARY /
VOCATIONAL PEÑARANDA NATIONAL HIGH SCHOOL 6/1/2008 3/27/2012 2012 N

TRADE
NUEVA ECIJA UNIVERSITY OF SCIENCE AND BACHELOR OF SECONDARY EDUCATION
COURSE
COLLEGE
TECHNOLOGY (PEÑARANDA CAMPUS) MAJOR IN MAPEH
6/1/2012 4/6/2017 2017
GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE November 11, 2019

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
BOARD LICENSURE EXAMINATION FOR
81.0 09/25/2017 BAGUIO CITY, BENGUET 1589291 12/18/2020
PROFESSIONAL TEACHERS

(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
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)
SAN LORENZO RUIZ DIOCESAN ACADEMY,
6/1/2017 4/1/2018 TEACHER 8999.00 CONTRACTUAL
INC
5/20/2018 7/20/2018 JOB ORDER LOCAL GOVERNMENT OF PEÑARANDA 4000.00 CONTRACTUAL

SAN LORENZO RUIZ DIOCESAN ACADEMY,

8/1/2018 PRESENT TEACHER 11999.00 CONTRACTUAL
INC
NUEVA ECIJA UNIVERSITY OF SCIENCE
125/ PER
4/8/2019 PRESENT PART-TIME LECTURER AND TECHNOLOGY (PEÑARANDA OFF- HOUR
CONTRACTUAL
CAMPUS
 (Continue on separate sheet if necessary)

SIGNATURE DATE 01/07/2019

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

(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
ATTENDANCE Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To
EDUCATIONAL TECHNOLOGY: EMPOWERING THE 21ST CENTURY TEACHERS WITH THE NEUST- PEÑARANDA ACADEMIC EXTENSION
4/3/2016 6/3/2016 3 DAYS
MODERN TRENDS IN TEACHING CAMPUS

DIVISION TRAINING IN COACHING DIFFERENT SPORTS DISCIPLINE IN PRIVATE SCHOOLS 11/8/2018 08 25 2018 3 DAYS SCHOOLS DIVISION OF NUEVA ECIJA

2019 INSET FOR JHS TEACHERS "DESIGNING, ASSESING, AND FACILITATING LEARNING
04/29/2019 1/5/2019 3 DAYS PRIVATE EDUCATIONAL ASSISTANCE COMMITTEE
OF THE K TO 12 STANDARDS WITH 21ST CENTURY PEDAGOGIES
CAPABILITY TRAINING AND ACCREDITATION OF COACHES AND TECHNICAL OFFICIALS
05/27/2019 05/29/2019 3 DAYS SCHOOLS DIVISION OF NUEVA ECIJA
IN DIFFERENT SPORTS EVENTS

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

PUBLIC SPEAKING GERRY ROXAS LEADERSHIP AWARDEE

 MS OFFICE WORKS PEACE AMBASSADOR OF THE YEAR

COACHING VOLLEYBALL DANCER OF THE YEAR

JOURNALIST OF THE YEAR

GOLD AWARD FOR LEADERSHIP

MOST OUTSTANDING PRE-SERVICE TEACHER

(Continue on separate sheet if necessary)

SIGNATURE DATE 01/07/2019

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 ✘ NO
YES ✘ NO
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
________________________________
YES ✘ NO
35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
YES ________________________________
✘ NO
b. Have you been criminally charged before any court?
If YES, give details:
________________________________
Date Filed:
________________________________
YES Status of✘Case/s:
NO
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:
YES ________________________________
✘ NO
________________________________
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? YES ✘ NO
________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
YES ✘ NO
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last
YES ✘ NO
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):

YES ✘ NO
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: YES ✘ NO
a. Are you a member of any indigenous group?
YES If YES, please✘ specify:
NO
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
POBLACION I, PEÑARANDA, NUEVA the last 6 months
MR. MARVIN SANCHEZ ECIJA
0917-129-4467 3.5 cm. X 4.5 cm
(passport size)
POBLACION IV, PEÑARANDA, NUEVA
MR. MARWAN ABESAMIS ECIJA
0917-149-4911 With full and handwritten
name tag and signature over
printed name

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 filing of PHOTO
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:

ID/License/Passport No.: 1589291 Signature (Sign inside the box)

NOVEMBER 7, 2019
Date/Place of Issuance: 12/15/2017/ BAGUIO CITY
Date/Place of Issuance: 12/15/2017/ BAGUIO 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