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 LANGUIDO
NAME EXTENSION (JR., SR)
FIRST NAME ABIGAIL

MIDDLE NAME BUTAC

3. DATE OF BIRTH
03/26/1994 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
✘
by by
birth naturalization
4. PLACE OF BIRTH BENITO SOLIVEN, ISABELA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS KAINYOGAN

House/Block/Lot No. Street
Separat
Widowed YEBAN NORTE
Other/s: ed Subdivision/Village Barangay
BENITO SOLIVEN ISABELA
7. HEIGHT (m) 5'3"
City/Municipality Province
8. WEIGHT (kg) 55KG ZIP CODE 3301

18. PERMANENT ADDRESS KAINYOGAN

9. BLOOD TYPE A+
House/Block/Lot No. Street
YEBAN NORTE
10. GSIS ID NO.
Subdivision/Village Barangay
BENITO SOLIVEN ISABELA
11. PAG-IBIG ID NO. 1211-3736-2534
City/Municipality Province

12. PHILHEALTH NO. 06-025194379-9 ZIP CODE 3301

13. SSS NO. 01-2769747-7 19. TELEPHONE NO. N/A

14. TIN NO. 464-487-540 20. MOBILE NO. 0926-2782-898

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) languidomakoabigail1234@gmail.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 LANGUIDO 08/07/1971

NAME EXTENSION (JR., SR)
FIRST NAME RODOLFO

MIDDLE NAME CARPIO

25. MOTHER'S MAIDEN NAME

SURNAME BUTAC 09/05/1973

FIRST NAME OFELIA

MIDDLE NAME RINION (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

ELEMENTARY YEBAN INTEGRATED SCHOOL ELEMENTARY 06/01/2002 03/26/2007 GRADUATED 2007

6TH HONORABLE
SECONDARY /
VOCATIONAL YEBAN INTEGRATED SCHOOL SECONDARY 06/01/2007 03/27/2010 GRADUATED 2010 MENTIONED

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

TRADE
COURSE
COLLEGE ISABELA STATE UNIVERSITY-ILAGAN CAMPUS DIPLOMA IN MIDWIFERY 06/01/2010 03/27/2012 GRADUATED 2012

F.L VARGAS COLLEGE-TUGUEGARAO CITY BACHELOR OF SCIENCE IN MIDWIFERY 06/01/2018 05/15/2019 GRADUATED 2019
(Continue on separate sheet if necessary)

SIGNATURE DATE May 7,2021

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

MIDWIFERY LINCENSURE EXAMINATION 81.55% NOV. 16-18 2012 MANUEL L. QUEZON UNIVERSITY MANILA 0161898 03-26-2021

(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
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To
(Y/ N)
POPULATION REPRESENTATIVE 5TH, COMMISSION ON POPULATION REGIONAL
01/01/2020 04/30/2020 P21,000.00 10 JOB ORDER YES
6TH DISTRICT OF ISABELA OFFICE 2
COMMISSION ON POPULATION REGIONAL
09/01/2019 12/31/2019 CAUAYAN CITY COODINATOR P21,000.00 10 JOB ORDER YES
OFFICE 2
06/23/2019 08/31/2019 NURSING ATTENDANT/SALES OFFICER BRIGADA NEWS FM 92.9 P5,500.00 RELIEVER NO

01/01/2019 05/31/2019 ASSISTANT SURGEON SEGUNDO MEDICAL CLINIC P8,000.00 TEMPORARY NO

RURAL HEALTH MIDWIFE PLACEMENT
01/01/2018 12/31/2018 DEPARTMENT OF HEALTH P20,179.00 10 CONTRACTUAL YES
PROGRAM
RURAL HEALTH MIDWIFE PLACEMENT
02/01/2015 12/31/2016 DEPARTMENT OF HEALTH P14,000.00 5 CONTRACTUAL YES
PROGRAM
LOCAL GOVERNMENT UNIT BENITO
12/01/2013 01/31/2013 MIDWIFE CASUAL P3,850.00 CASUAL YES
SOLIVEN, ISABELA
02/28/2013 11/30/2013 MIDWIFE TRAINEE DEPARTMENT OF HEALTH P6,000.00 TRAINEE YES
LOCAL GOVERNMENT UNIT BENITO
01/01/2013 02/28/2013 VOLUNTEER VOLUNTEER YES
SOLIVEN, ISABELA

(Continue on separate sheet if necessary)

SIGNATURE DATE May 7,2021

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
DECEMBER DECEMBER LOCAL GOVERNMENT UNIT BENITO SOLIVEN,
PROMOTION OF GOOD NUTRITION INFANT YOUNG CARE AND FEEDING 40.0
8,2014 12,2014 ISABELA
AUGUST AUGUST PROVINCIAL RISK REDUCTION MANAGEMENT
BASIC LIFE SUPPORT/FIRST AID TRAINING 24.0
18,2016 20,2016
OCTOBER OCTOBER
HATAW EXERCISE WORKSHOP 24.0 DEPARTMENT OF HEALTH
3,2017 5,2017
OCTOBER INTEGRATED MIDWIVES ASSOCIATION
MIDWIVES IN THE SUSTAINABILITY OF MATERNAL AND CHILD HEALTH 8.0
29,2017 PHILIPPINES
DECEMBER
STI-HIV AIDS AWARENESS CAMPAIGN 8.0 DEPARTMENT OF HEALTH
14,2018

(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)

COMMUNICATION SKILLS
 (Continue on separate sheet if necessary)

SIGNATURE DATE May 7,2021

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 ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘

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
YES ✘ NO
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
ROUCHEL PAREJA CAUAYAN CITY, ISABELA 09176565062 3.5 cm. X 4.5 cm
(passport size)

CLEFFORD TAGAPAN BENITO SOLIVEN, ISABELA 09369672704 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: PRC ID

ID/License/Passport No.: 0161898

Signature (Sign inside the box)
May 7,2021
Date/Place of Issuance: PRC TUGUEGARAO 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