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)

2. SURNAME ROSQUETA
NAME EXTENSION (JR., SR) N/A
FIRST NAME JOHN RAYMOND

MIDDLE NAME LAGDA

3. DATE OF BIRTH
(mm/dd/yyyy) 3/1/1996 16. CITIZENSHIP ✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH Marcos, Ilocos Norte If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

✘ Single Married 17. RESIDENTIAL ADDRESS

6 CIVIL STATUS
Widowed ✘ Separated House/Block/Lot No. Street
Other/s: CALI
Subdivision/Village Barangay
DINGRAS ILOCOS NORTE
7. HEIGHT (m) 1.58
City/Municipality Province
8. WEIGHT (kg) 70 ZIP CODE 2913

18. PERMANENT ADDRESS

9. BLOOD TYPE O
House/Block/Lot No. Street
CALI
10. GSIS ID NO. N/A
Subdivision/Village Barangay
DINGRAS ILOCOS NORTE
11. PAG-IBIG ID NO. N/A
City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 2913

13. SSS NO. 01-2714010-2 19. TELEPHONE NO. N/A

14. TIN NO. 711,571,776,000 20. MOBILE NO. 09612332097

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) johnraymond.rosqueta@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)
FIRST NAME N/A 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 ROSQUETA

NAME EXTENSION (JR., SR)
FIRST NAME JOEL

MIDDLE NAME MONTE

25. MOTHER'S MAIDEN NAME

SURNAME LAGDA

FIRST NAME ANELIA

MIDDLE NAME BALANTAC (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 GRADUATED
(Write in full) EARNED HONORS
full) (if not graduated) RECEIVED
From To

ELEMENTARY SALUDARES-CALI ELEMENTARY SCHOOL ELEMENTARY 3/6/2002 5/4/2008 N/A 2008 VALEDICTORIAN

DINGRAS NATIONAL HIGH SCHOOL-POBLACION

SECONDARY /
VOCATIONAL CAMPUS
HIGH SCHOOL 9/6/2008 9/4/2012 N/A 2012 N/A

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

TRADE
Mariano Marcos State University- College of Teacher
COURSE
COLLEGE
Education
BACHELOR OF ELEMENTARY EDUCATION 8/6/2012 6/4/2016 N/A 2016 N/A

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 02/14/2020

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
BOARD LICENSURE EXAMINATION FOR
76.8 09/25/2016 LAOAG CITY 1510543 12/17/2016
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 SERVICE
28. INCLUSIVE DATES SALARY/ JOB/ PAY
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)
ST. JOSEPH EDUCATIONAL CENTER OF
06/15/2017 10/4/2018 TEACHER 7040.00 N/A Contractual N
DINGRAS INC.
10/1/2018 11/29/2018 TEACHER I ( Substitute) ESPIRITU ELEMENTARY SCHOOL 20179.00 11 Substitute Y

12/3/2018 1/31/2019 Teacher 1 (Substitute) CARAITAN INTEGRATED SCHOOL 20179.00 11 Substitute Y

3/3/2019 04/16/2019 Teacher 1 (Substitute) Nueva Era Central Elementary School 20179.00 11 Substitute Y

5/9/2019 11/26/2019 Teacher 1 (Substitute) Dingras West Central Elementary School 20179.00 11 Substitute Y

(Continue on separate sheet if necessary)

SIGNATURE DATE 02/14/2020

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

N/A 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 ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

Workshop on Information and Communication Technology (Digital Citizenship) 06/17/2017 06/17/2018 8 Technical CK Children's Publishing

Seminar Workshop on Continuing Professional Development: An Ethical and Professional

6/5/2017 6/5/2017 8 Technical Norphil Innovative Center for Education
Obligation
Seminar Workshop on Interactive, Integrative, Collaborative Teaching Strategies and
4/2/2017 4/2/2017 8 Technical Norphil Innovative Center for Education
Outcomes/Competency-Based Assestment for Higher Order Thinking Skills

(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)

Computer Literate N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 02/14/2020

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
by any court or tribunal?
If YES, YES
give details: ✘ 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 YES ✘ NO
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
Barangay election)?
If YES,YES
give details: ✘ NO

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, YES NO
✘
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 specify:
If YES, please ✘ NO
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. Romualdo Pascua Dingras, Ilocos Norte 9989728172 3.5 cm. X 4.5 cm
(passport size)

Mrs. Marissa Aurellano Badoc, Ilocos Norte 9171440206 With full and handwritten
name tag and signature over
printed name
Mr. Francis M. Jose Dingras, Ilocos Norte 9253172574
Computer generated
or photocopied picture
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and 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/License/Passport No.: 1510543

Signature (Sign inside the box)
02/14/2020
Date/Place of Issuance: 12/17/2016/Laoag 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