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
2. SURNAME FRIAS

FIRST NAME ARSENIO NAME EXTENSION (JR., SR) JR.

MIDDLE NAME GUPITA

3. DATE OF BIRTH
(mm/dd/yyyy) 1/17/1998 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH MATAGDEM, SAN CARLOS CITY, PANGASINAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS 405 ROAD 3
Widowed Separated House/Block/Lot No. Street
N/A MATAGDEM
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 1.72 SAN CARLOS CITY PANGASINAN
City/Municipality Province
8. WEIGHT (kg) 52 ZIP CODE 2420

9. BLOOD TYPE O
18. PERMANENT ADDRESS 405 ROAD 3
House/Block/Lot No. Street

10. GSIS ID NO. n/a

N/A MATAGDEM
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1212-3163-4565 SAN CARLOS CITY PANGASINAN

City/Municipality Province

12. PHILHEALTH NO. 05-251718079-3 ZIP CODE 2420

13. SSS NO. 02-4434808-1 19. TELEPHONE NO. N/A

14. TIN NO. 735836304 20. MOBILE NO. 0946 034 3385

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) arseniofrias_17@yahoo.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) N/A
FIRST NAME N/A N/A

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME FRIAS

SR.
FIRST NAME ARSENIO

MIDDLE NAME MENDOZA

25. MOTHER'S MAIDEN NAME CAMILA IBAÑO GUPITA

SURNAME FRIAS

FIRST NAME CAMILA

MIDDLE NAME GUPITA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

4TH Honorable
ELEMENTARY DOYONG ELEMENTARY SCHOOL ELEMENTARY 2004 2010 N/A 2010 Mention

SECONDARY
VOCATIONAL / DOYONG NATIONAL HIGH SCHOOL SECONDARY 2010 2014 N/A 2014 Salutatorian

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

TRADE
COURSE PANGASINAN STATE UNIVERSITY SAN Magna Cum
COLLEGE
CARLOS CAMPUS
BACHELOR OF SECONDARY EDUCATION 2014 2018 N/A 2018 Laude

PANGASINAN STATE UNIVERSITY URDANETA CITY MASTER OF EDUCATION MAJOR IN SOCIAL

GRADUATE STUDIES
CAMPUS STUDIES 2020 Present N/A on going N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE November 5, 2020 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

LET (LICENSURE EXAMINATION FOR TEACHER) 9/30/2018 ROSALES,PANGASINAN 1721160 1/20/2019

CIVIL SERVICE ELIGIBILITY 6/19/2018 LINGAYEN, PANGASINAN 6/19/2018

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

MOTHER GOOSE SPECIAL SCHOOL SYSTEM,

6/1/2018 PRESENT FACULTY INCORPORATED
10500.00 N/A CONTRACTUAL NO

(Continue on separate sheet if necessary)

SIGNATURE DATE February 14, 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 NUMBER OF
(Write in full) (mm/dd/yyyy) HOURS POSITION / NATURE OF WORK
From To

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

AFTA (Association of FIL-AM Teachers of America, Inc.) Balikturo Online 2020 7/21/2020 7/25/2020 22 AFTA (Association of FIL-AM Teachers of America, Inc.)
Fifteen (15) Day Basic Computer Training 7/6/2020 7/22/2020 15 days Myrn`s Internet Café, Malasiqui Pangasinan
Department of Education and Private Education Assistance
2019 SUMMER DepEd-PEAC IN SERVICE TRAINING (INSET) FOR JUNIOR HIGH SCHOOL 5/27/2019 5/29/2019 24 (3days)
Committee
(JHS) TEACHERS IN PRIVATE SCHOOLS
WHOLE CHILD EDUCATION AND 21ST CENTURY ASSESSMENT STRATEGIES 3/2/2019 3/2/2019 8 Resource for Educators and Academic Professionals

DIVISION SEMINAR-WORKSHOP ON PPST-RPMS FOR PRIVATE SCHOOL HEADS AND Department of Education (Schools Division Office of Urdaneta
2/1/2019 2/3/2019 24 (3days)
TEACHERS City)

Mother Goose Special School System, Incorporated (Special

TEACHER`S ORIENTATION 2018 6/13/2018 6/14/2018 24 (3days)
Science High School)

2018 SUMMER DepEd-PEAC IN SERVICE TRAINING (INSET) FOR JUNIOR HIGH SCHOOL
Department of Education and Private Education Assistance
(JHS) TEACHERS IIN PRIVATE SCHOOLS (DESIGNING, ASSESSING 4/23/2018 4/25/2018 24 (3days)
Committee
AND FACILITATING LEARNING FOR K-12 CURRICULUM STANDARDS)

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMBERSHIP IN ASSOCIATION/ORGANIZATION

31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full) (Write in full)

Youth Leader Outstanding Youth Leader Awardee Sangguniang Kabataan ng Barangay Matagdem

Journalism n/a n/a

Public Speaking/Oration n/a n/a

Singing n/a n/a

Dancing n/a n/a

(Continue on separate sheet if necessary)

SIGNATURE DATE February 14, 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
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘ NO
If YES, give details:
________________________________

35. a. Have you ever been found guilty of any administrative offense? YES ✘ NO
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court? YES ✘ NO
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 NO
YES ✘
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, YES ✘ NO
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
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?
YES ✘ NO
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? YES ✘ NO
If YES, please specify:
b. Are you a person with disability? YES ✘ NO
If YES, please specify ID No:
c. Are you a solo parent? YES ✘ NO
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
MR. MICHAEL FERRER SAN CARLOS CITY, PANGASINAN 9469968468 3.5 cm. X 4.5 cm
(passport size)

DR. CRISTINA L. JAVIER MALASIQUI, PANGASINAN 9098291962 With full and handwritten
name tag and signature over
printed name
MS. RHENEA LIZLIE B. SANCHEZ BINMALEY, PANGASINAN 9434018878
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete or photocopied picture
is not acceptable
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 PHOTO
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 LICENSE I.D

ID/License/Passport No.: 1721160

Signature (Sign inside the box)
February 14, 2019
Date/Place of Issuance: CALASIAO, PANGASINAN
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