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 PADAGDAG
NAME EXTENSION (JR., SR) NONE
FIRST NAME MICHAEL

MIDDLE NAME GAPOL

3. DATE OF BIRTH
(mm/dd/yyyy) 09/29/1988 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH NEGROS ORIENTAL CANLAON CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX
✘ Male ✘ Female
17. RESIDENTIAL ADDRESS
6 CIVIL STATUS Single ✘ Married House/Block/Lot No. Street
Widowed Separate 7 BACUBAC
Other/s: d Subdivision/Village Barangay
BASEY SAMAR
7. HEIGHT (m) 1.72 M
City/Municipality Province
8. WEIGHT (kg) 70 ZIP CODE 6720
18. PERMANENT ADDRESS
9. BLOOD TYPE B+
House/Block/Lot No. Street
BACUBAC
10. GSIS ID NO. 021-1695-6550-7
Subdivision/Village Barangay

11. PAG-IBIG ID NO. NONE BASEY SAMAR

City/Municipality Province

12. PHILHEALTH NO. 13-050155261-6 ZIP CODE 6720

13. SSS NO. 06-3457815-7 19. TELEPHONE NO. NONE

14. TIN NO. 494-378-034-000 20. MOBILE NO. 9514721581

15. AGENCY EMPLOYEE NO.
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME
FIRST NAME
062794 21. E-MAIL ADDRESS (if any) mikepadagdag25@gmail.com
PADAGDAG 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) NAMIE S. PADAGDAG
ROGELYN NOV. 5, 2018

MIDDLE NAME SABONG

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS
TELEPHONE NO.

24. FATHER'S SURNAME PADAGDAG

NAME EXTENSION (JR., SR)
FIRST NAME NESTOR

MIDDLE NAME DESABILLE

25. MOTHER'S MAIDEN NAME

SURNAME GAPOL

FIRST NAME ESTRELLITA

MIDDLE NAME RICHA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY BASEY 1 CENTRAL ELEMENTARY SCHOOL ELEMENTARY EDUCATION 1995 2001 N/A 2001 NONE

VALERIAN C. YANCHA MEMORIAL AGRICULTURAL

SECONDARY /
VOCATIONAL SCHOOL
HIGH SCHOOL 2001 2007 N/A 2007 NONE

AMA COMPUTER LERANING CENTER WEB APPLICATIONS DEVELOPMENT 2008 2010 N/A 2010 NONE

TRADE
BACHELOR OF SCIENCE IN INFORMATION
COURSE AMA COMPUTER LERANING CENTER
TECHNOLOGY
2010 2013 N/A 2013 NONE
COLLEGE
BACHELOR OF SECONDARY EDUCATION
LEYTE COLLEGES
MAJOR - SOCIAL SCIENCE
2017 2017 18 UNITS

GRADUATE STUDIES NONE

(Continue on separate sheet if necessary)

SIGNATURE DATE FEBRUARY 21, 2022

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
LEYTE NATIONAL HIGH SCHOOL TACLOBAN
LET 79.2 09/26/2021 1884770 09/29/2025
CITY

(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)

09/26/2016 PRESENT SENIOR HIGH SCHOOLTEACHER DEPARTMENT OF EDUCATION 26,052 SG 12 PROVISIONAL Y

06/20/2012 09/20/2013 INSTRUCTOR EASTERN VISAYAS TECHNICAL COLLEGE 3,000.00 N/A CONTRACTUAL N

(Continue on separate sheet if necessary)

SIGNATURE DATE FEBRUARY 21, 2022

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

NONE

(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

LIS ORIENTATION 7/6/2019 10/6/2019 16 TECHNICAL DEPARTMENT OF EDUCATION

NATIONAL CERTIFICATE LEVEL II (CSS) 10/10/2017 11/5/2017 240 TECHNICAL TESDA

WEB DEVELOPMENT WITH MOBILE APP 10/20/2017 11/25/2017 240 TECHNICAL TESDA

TRAINERS METHODOLOGY LEVEL I 10/11/2017 11/24/2017 260 TECHNICAL DEPARTMENT OF EDUCATION

DISTRICT TRAINING-WORKSHOP ON THE IMPLEMENTATION OF PROJECT HI-TEACH 10/26/2017 10/28/2017 24 TECHNICAL DEPARTMENT OF EDUCATION

CONDUCT OF SENIOR HIGH SCHOOLS IMMERSION FORUM 9/15/2017 9/15/2017 8 TECHNICAL DEPARTMENT OF EDUCATION

DIVISION TRAINING ON COACHING AND OFFICIATING OF DIFFERENT SPORTS EVENTS

9/8/2017 9/10/2017 24 TECHNICAL DEPARTMENT OF EDUCATION
FOR BEGINNERS

INCLUED 8 ENUMERATORS 08/17/2017 08/19/2017 24 TECHNICAL MOOE

JOB ORIENTATION FOR NEWLY-HIRED TEACHER 3/6/2017 3/8/2017 24 TECHNICAL DEPARTMENT OF EDUCATION

CONTINUOUS IMPROVEMENT (CI) PROJECT 1/10/2017 07/13/2017 168 TECHNICAL DEPARTMENT OF EDUCATION

(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)

BASKETBALL CERTIFICATE OF PARTICIPATION AS INCLUED 8 ENUMERATORS KNIGHTS OF COLUMBUS

ICT SPAA OFFICIATING TECHNICAL OFFICIAL 2017-2018

CERTIFICATE OF RECOGNITION IN 2017 DIVISION FESTIVAL OF TALENTS -
TECHNOLYMICS
CERTIFICAE OF RECOGNITION OF ALAY LINIS SA BARANGAY
OREINTATION AND TRAINING ON ENVIRONMENTAL EDUCATION AND WATER QUALITY
MONITORING AND MANAGEMENT
TRAININGOF DESO TECHNICAL SUPPORT STAFF

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 12, 2022

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:
________________________________
________________________________
YES ✘ NO
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 YES ✘ NO
by any court or tribunal?
If YES, give details:
________________________________
________________________________
✘ NO
37. Have you ever been separated from the service in any of the following modes: resignation, YES
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
Barangay election)?
If YES, give details:
YES ✘ NO
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:
YES ✘ NO
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 items: YES ✘ NO
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?
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
NOLI D. PADAGDAG DOST REGIONAL OFFICE 3.5 cm. X 4.5 cm
(passport size)

JINKY M. VILLAR BASEY NATIONAL HIGH SCHOOL With full and handwritten
name tag and signature over
printed name
CESAR C. SILAY ITECH SOLUTIONS & TRAINIING CENTER
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: BIR

ID/License/Passport No.: 494-378-034-000

Signature (Sign inside the box)
JANUARY 12, 2022
Date/Place of Issuance: CATBALOGAN
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