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 ABAINZA
NAME EXTENSION (JR., SR)
FIRST NAME ELMER
MIDDLE NAME OBLINO
3. DATE OF BIRTH
(mm/dd/yyyy) 5/1/1990 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH CATBALOGAN, SAMAR If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS PUROK 1 N/A

House/Block/Lot No. Street
Widowed
Separated N/A BRGY CANLAPWAS
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 1.676 CATBALOGAN CITY SAMAR
City/Municipality Province
8. WEIGHT (kg) 64 ZIP CODE 6700
9. BLOOD TYPE O
18. PERMANENT ADDRESS PUROK 1 N/A
House/Block/Lot No. Street

10. GSIS ID NO. N/A N/A BRGY CANLAPWAS

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1212-2488-3137 CATBALOGAN CITY SAMAR

City/Municipality Province

12. PHILHEALTH NO. 13-201187797-8 ZIP CODE 6700

13. SSS NO. 0424437275 19. TELEPHONE NO. N/A
14. TIN NO. 727-263-510 20. MOBILE NO. 09300257137
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) elmerabainza05@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/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 ABAINZA
NAME EXTENSION (JR., SR)
FIRST NAME ERNESTO
MIDDLE NAME CADLIT
25. MOTHER'S MAIDEN NAME MODESTA DACUTANAN OBLINO

SURNAME OBLINO
FIRST NAME MODESTA
MIDDLE NAME DACUTANAN (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

CATBALOGAN III CENTRAL

ELEMENTARY ELEMENTARY GRDAUTE 1997 2003 N/A 2003 N/A
ELEMENTARY SCHOOL
SECONDARY SAMAR NATIONAL SCHOOL HIGH SCHOOL GRADUATE 2003 2007 N/A 2007 N/A
VOCATIONAL /

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

TRADE
BACHELOR OF SCIENCE IN INFORMATION
COURSE
COLLEGE SAMAR STATE UNIVERSITY TECHNOLOGY
2007 2011 N/A 2011 N/A

MASTER OF ARTS IN EDUCATION MAJOR

SAMAR COLLEGES, INC. EDUCATIONAL MANAGEMENT
2019 2019 9 UNITS N/A N/A

GRADUATE STUDIES

DIPLOMA IN TEACHING MAJOR IN

SAMAR STATE UNIVERSITY TECHNOLOGY AND LIVELIHOOD EDUCATION
2015 2017 N/A 2017 N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE
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

LICENSURE EXAMINATION FOR TEACHER 77.20 6/24/2022 TACLOBAN CITY, LEYTE 1945178 5/1/2025

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

6/4/2018 6/4/2022 TEACHER SAMAR COLLEGES, INC. 10,400 N/A PROBATIONARY N

6/5/2017 3/30/2018 TEACHER SAINT MICHAELS HIGH SCHOOL 6,500 N/A CONTRACTUAL N

2/1/2013 5/15/2017 COMPUTER MAINTENANCE JOEMARY'S INTERNET CAFÉ 4,000 N/A PERMANENT N

(Continue on separate sheet if necessary)

SIGNATURE DATE
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

St. Isidore de Labrador Technical School, Inc. -

National Certificate II in Computer System Servicing 10/27/2022 10/27/2022 8 HOURS TECHNICAL
Technical Education and Skills Development Authority

2021 INSET for SHS Teachers (Additional Runs Online) with the theme Facilitating Learning in a Department of Education - Private Education
2/28/2022 3/2/2022 16 HOURS TECHNICAL
SHS Flexible Class Assisstance Committee

Samar Colleges, Inc. - Technical Education and Skills

National Certificate II in Cookery 10/15/2017 12/2/2019 316 HOURS TECHNICAL
Development Authority

Samar Colleges, Inc. in Cooperation with REX

2-day Seminar workshop in Current Trends in Teaching Strategies and Approaches 11/21/2019 11/22/2019 12 HOURS TECHNICAL
Bookstore

3-day training on Seminar-Workshop on the K-12 Teaching and Learning 10/21/2019 10/23/2019 16 HOURS TECHNICAL SHS Department, Samar Colleges, Inc.

1-day seminar-Workd]shop in Enhancing SHS Teachers’ Pedagogical Content Knowledge in

6/8/2019 6/8/2019 8 HOURS TECHNICAL Philippine Normal University
Specialized Courses in Academic Tracks of the Curriculum

Seminar-Workshop on Interfacing Brain-Based Learning with Transformative Teaching for

3/16/2019 3/16/2019 8 HOURS TECHNICAL Phoenix Publishing House
NextGen Learners in HUMSS

2018 Summer DepEd-PEAC In-Service Training (INSET) for SHS Teachers in Private Schools on Department of Education - Private Education
5/25/2018 5/27/2018 16 HOURS TECHNICAL
Improving SHS Teachers’ Pedagogical Content Knowledge (PCK) on Articulated Competencies Assisstance Committee

Training-Workshop on the Enhancing of Contextualized Interactive Learning Materials 9/19/2017 9/21/2017 16 HOURS TECHNICAL Departement of Education, Division of Samar

Department of Education - Private Education

2017 DepEd-PEAC In-Service Training (INSET) for SHS Teachers 5/26/2017 5/28/2017 16 HOURS TECHNICAL
Assisstance Committee

Demonstration Teaching during the 2017 DepEd-PEAC In-Service Training (INSET) for SHS Department of Education - Private Education
5/26/2017 5/28/2017 16 HOURS TECHNICAL
Teachers Assisstance Committee

National Certificate II in Food Processing 9/5/2015 9/5/2015 8 HOURS TECHNICAL Technical Education and Skills Development Authority

National Certificate II in Computer Hardware Servicing 3/31/2011 3/31/2011 8 HOURS TECHNICAL Technical Education and Skills Development Authority

(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)

TROUBLESHOOTING N/A N/A

SOFTWARE UPDATES
MASTERY OF MICROSOFT OFFICE & OTHER
ONLINE TOOLS
COMPUTER NETWORKS

COOKERY

(Continue on separate sheet if necessary)

SIGNATURE DATE
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
ABE JOY S. CABERO CATBALOGAN CITY 9363423268 3.5 cm. X 4.5 cm
(passport size)

MR. ROBERTO V. MABULAC CATBALOGAN CITY 9558164739 With full and handwritten
name tag and signature over
printed name
S. ALELE TAN, FAS GANDARA, SAMAR 9281838027
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.: 1945178 Signature (Sign inside the box)

Date/Place of Issuance: 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