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 PRIMA
NAME EXTENSION (JR., SR) JR
FIRST NAME ROLEN

MIDDLE NAME BARCELA

3. DATE OF BIRTH
(mm/dd/yyyy) 2/21/1997 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH Bagong Sirang, Camarines Sur If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

✘ Single Married 17. RESIDENTIAL ADDRESS Blk 24. Lt 56

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
Zone 5 Bagong Sirang
Other/s:
Subdivision/Village Barangay
Pili Camarines Sur
7. HEIGHT (m) 1.67 m
City/Municipality Province
8. WEIGHT (kg) 52 kg. ZIP CODE 4410
18. PERMANENT ADDRESS
9. BLOOD TYPE 0
House/Block/Lot No. Street

10. GSIS ID NO. none

Subdivision/Village Barangay

11. PAG-IBIG ID NO.

Bagong Sirang Camarines Sur
City/Municipality Province
12. PHILHEALTH NO. 34-8727758-9 ZIP CODE

13. SSS NO. 05-0531012-7 19. TELEPHONE NO. None

14. TIN NO. 182-742-183 20. MOBILE NO. 09703148025

15. AGENCY EMPLOYEE NO. AP4-1-1-2017 21. E-MAIL ADDRESS (if any) rolen.prima@cbsua.edu.ph

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME Not Applicable 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
FIRST NAME NAME EXTENSION (JR., SR) Not Applicable
Not Applicable
MIDDLE NAME
OCCUPATION
EMPLOYER/BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.

24. FATHER'S SURNAME PRIMA

NAME EXTENSION (JR., SR) SR
FIRST NAME ROLAND

MIDDLE NAME MANDI

25. MOTHER'S MAIDEN NAME

SURNAME PRIMA

FIRST NAME MARILYN

MIDDLE NAME TINGGAN (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
UNITS ACADEMIC
LEVEL (Write in full) EARNED
GRADUATED
HONORS
(Write in full) (if not RECEIVED
From To
graduated)
Class
ELEMENTARY Bagong Sirang Elementary School Primary Education 2003 2010 2010 Valedictorian
VOCATIONAL / Computer Science Highs School Of
SECONDARY
Bicolandia
High School 2010 2014 2014 None

COLLEGE TRADE CBSUA Pili Campus Bachelor of Secondary Education(EMT) 2014 2022 2022
COURSE

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE September 29, 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

none

(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/ SERVICE
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY PAY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To
(Y/ N)
03/29/2021 Present Photographer/Videographer PIXEL PRIME 10,000.00 COS N

03/29/2021 Present Photographer/Videographer PIXEL PRIME 10,000.00 COS N

07/1
6/20 Present Administrative Aide III Central Bicol State University of Agriculture 15,000.00 COS N
19

(Continue on separate sheet if necessary)

SIGNATURE DATE September 29, 2022

CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (Write in
full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

Bagong Sirang Youth Organization (BSYO) 4/12/2016 4/12/2018 Youth President

Federation of Pili Yputh Org.(FPYO) BATCH 1-2 6/7/2017 6/7/2019 Treasurer

KAPOT Pili Chapter 07/20/2018 07/20/2020 Youth Leader

TILAD Pili 12/2/2015 12/2/2016 Member

(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
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) From To Technical/etc)

Technical & Video

CBSUA Interanational Accreditation 2022 02/15/2022 02/25/2022 40.0 editor
CBSUA Pili
Over-all Technical
Arts Month Celebration 2022 2/17/2022 2/28/2022 50.0 & Video Editor
CBSUA Pili
Over-all Technical
Webinar on Bicol Culture & Literary Arts Festival 2021 11/25/2022 11/26/2022 16.0 & Video Editor
CBSUA Pili
Over-all Technical
Webinar on Buwan Ng Wika Celebration 2021 8/26/2021 8/28/2021 36.0 & Video Editor
CBSUA Pili
Over-all Technical
Webinar on National Heritage Month Celebration 2021 6/16/2021 6/18/2021 36.0 & Video Editor
CBSUA Pili
Over-all Technical
Webinar on Buwan ng Panikan 2021 4/15/2021 4/15/2021 8.0 & Video Editor
CBSUA Pili
Over-all Technical
Arts Month Celebration 2021(Symposium & Webinar) 2/17/2021 02/25/2021 40.0 & Video Editor
CBSUA Pili
Over-all Technical
CBSUA Got Talent 2020 12/15/2020 12/17/2020 36.0 & Video Editor
CBSUA Pili
Event organizer /
Arts Month Celebration 2020 2/17/2019 02/25/2020 36.0 Facilitatior
CBSUA Pili
Paricipation to Peñafrancia Francia Festival 2019
(CBSUA as One)
09/18/2019 09/21/2020 36.0 Facilitator
Naga Camarines Sur

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 33.
(Write in full) (Write in
full)
Computer Editing (Vide and Picture Enhancing) Film & Media Arts (Adviser)

Photography and Videography

(Continue on separate sheet if necessary)

SIGNATURE DATE September 29, 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:
________________________________
________________________________
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
YES ✘ NO
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, YES ✘ NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or If YES, give details:
phased 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 YES ✘ NO
(except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
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?
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
Dr. Leopoldo R. Transona Jr.(SWK/ACA Director) CBSUA Pili 3.5 cm. X 4.5 cm
(passport size)

Dr. Ana E. Miraña(VPAA) CBSUA Pili With full and handwritten

name tag and signature over
printed name
Dr. Charlie P. Nacario CBSUA Pili
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 PHOTO
filing of 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:

ID/License/Passport No.:
Signature (Sign inside the box)
September 29, 2022
Date/Place of Issuance:
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