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

I. PERSONAL INFORMATION
2. SURNAME QUIMBO
NAME EXTENSION (JR., SR) : N/A
FIRST NAME REX

MIDDLE NAME CARELORIA

3. DATE OF BIRTH
(mm/dd/yyyy)
16. CITIZENSHIP FILIPINO
2/12/1997

4. PLACE OF BIRTH CALUBIAN, LEYTE If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX MALE
17. RESIDENTIAL ADDRESS
6 CIVIL STATUS
House/Block/Lot No. Street
SINGLE
LUCSOON
Subdivision/Village Barangay
NAVAL BILIRAN
7. HEIGHT (cm) 175 cm
City/Municipality Province
8. WEIGHT (kg) 62 kg ZIP CODE 6543

18. PERMANENT ADDRESS

9. BLOOD TYPE N/A
House/Block/Lot No. Street
LUCSOON
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A NAVAL BILIRAN

City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 6543

13. SSS NO. N/A 19. TELEPHONE NO. N/A

14. TIN NO. N/A 20. MOBILE NO. 09491590295 / 09561221812

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) rex.quimbo.50@gmail.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/yy
NAME EXTENSION (JR., SR) N/A
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 QUIMBO

NAME EXTENSION (JR., SR) N/A
FIRST NAME ERIC

MIDDLE NAME JAMOT

25. MOTHER'S MAIDEN NAME LOLITA BADILLA CARELORIA

SURNAME QUIMBO

FIRST NAME LOLITA

MIDDLE NAME CARELORIA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY CALUBIAN SOUTH CENTRAL SCHOOL ELEMENTARY 2003 2009 GRADUATED 2009

SECONDARY
VOCATIONAL / CALUBIAN NATIONAL HIGH SCHOOL HIGH SCHOOL 2009 2013 GRADUATED 2013

NONE N/A N/A N/A N/A N/A

TRADE
BACHELOR OF SECONDARY
COURSE
COLLEGE LEYTE NORMAL UNIVERSITY 2013 2017 N/A 2017
EDUCATION - MAPEH

GRADUATE STUDIES NONE N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 05/27/2022

CS FORM 212 (Revised 2017), Page
AL DATA SHEET
perience Sheet shall cause the filing of administrative/criminal case/s against the person concerned.

BEFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR) : N/A

FILIPINO

Pls. indicate country:

Street
LUCSOON
Barangay
BILIRAN
Province
6543

Street
LUCSOON
Barangay

Province

N/A

09491590295 / 09561221812

rex.quimbo.50@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

N/A

(Continue on separate sheet if necessary)

SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED
 SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED

NONE

NONE

N/A

NONE

NONE
ue on separate sheet if necessary)

05/27/2022
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
BOARD LICENSURE EXAMINATION FOR
81.00 09/30/2018 TACLOBAN CITY 1733693 12/2/2025
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)

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

 (Continue on separate sheet if necessary)

SIGNATURE DATE 05/27/2022

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

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
PHILIPPINE SPORTS COMMISSION / REBISCO
REBISCO VOLLEYBALL ACADEMY COACHES COURSE LEVEL I 12/4/2021 04/16/2021 32 HOURS TECHNICAL
VOLLEYBALL ACADEMY
PHILIPPINE SPORTS COMMISSION / REBISCO
REBISCO VOLLEYBALL LEAGUE ACCREDITED VOLLEYBALL COACH 12/4/2021 04/16/2021 32 HOURS TECHNICAL
VOLLEYBALL ACADEMY
10 DAYS BASIC COMPUTER LITERACY TRAINING (MS OFFICE WORD, MS EXCEL,
02/22/2019 03/07/2019 80 HOURS TECHNICAL JE MONDEJAR COMPUTER COLLEGE
POWERPOINT)

(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)

VOLLEYBALL PLAYER / COACH AWARD OF RECOGNITION (VOLLEYBALL - NATIONAL SCUAA ATHLETE 2017) CALUBIAN VOLLEYBALL ASSOCIATION
COMPUTER LITERATE AWARD OF MERIT (VOLLEYBALL - REGIONAL SCUAA GAMES MEDALIST) GS FAMILY VOLLEYBALL CLUB

SINGING AND DANCING

(Continue on separate sheet if necessary)

SIGNATURE DATE 05/27/2022

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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
________________________________

35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
________________________________
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
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,
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
Barangay election)?
If YES, give details:
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:
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:

a. Are you a member of any indigenous group?

If YES, please specify:
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

the last 6 months
3.5 cm. X 4.5 cm
NELLEN S. ALBEOS CALUBIAN, LEYTE (passport size)

With full and handwritten

CLEOFE T. PILANDE CALUBIAN, LEYTE name tag and signature over
printed name

Computer generated
LELITA D. GEMAOL CALUBIAN, LEYTE or photocopied picture
is not acceptable
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and
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: Professional Regulation Commission

ID/License/Passport No.: 1733693

Signature (Sign inside the box)

Date/Place of Issuance: 1/18/19 ; Tacloban 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