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 concerne

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. F

I. PERSONAL INFORMATION
2. SURNAME PALARAN

FIRST NAME KIMBERLY ANN N/A

MIDDLE NAME BACLAAN

3. DATE OF BIRTH
(mm/dd/yyyy)
7/18/1996
07/18/1996 16. CITIZENSHIP
✘ Filipino Dual Citizenship
✘ by birth by naturalizat
4. PLACE OF BIRTH BAYUGAN CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX
Male ✘ Female
6 CIVIL STATUS
17. RESIDENTIAL ADDRESS PUROK 2-C GAISANO EXTENSION
✘ Single Married House/Block/Lot No. Street
Widowed N/A TAGLATAWAN
Other/s: Separated
Subdivision/Village Barangay

7. HEIGHT (m) 1.5 BAYUGAN CITY AGUSAN DEL SUR

City/Municipality Province

8. WEIGHT (kg) 60 ZIP CODE 8502

9. BLOOD TYPE B+ 18. PERMANENT ADDRESS PUROK 2-C GAISANO EXTENSION

House/Block/Lot No. Street

10. GSIS ID NO. NO CRN N/A TAGLATAWAN

Subdivision/Village Barangay
BAYUGAN CITY AGUSAN DEL SUR
11. PAG-IBIG ID NO. 121273214138
City/Municipality Province

12. PHILHEALTH NO. 180253081250 ZIP CODE 8502

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

14. TIN NO. 760-199-893-000 20. MOBILE NO. +639501011161

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) kimberlypalaran@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/d
Name Extension (JR)
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 PALARAN
Name Extension (JR)
FIRST NAME RICKY
MIDDLE NAME AMBA
25. MOTHER'S MAIDEN NAME BACLAAN, MIRIAM JUBAY
SURNAME PALARAN
FIRST NAME MIRIAM
MIDDLE NAME BACLAAN Continue on separate sheet if neccesary

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL HIGHEST LEVEL/
26. PERIOD OF ATTENDANCE YEAR
BASIC EDUCATION/DEGREE/COURSE UNITS
LEVEL (Write in EARNED
GRADUATED
(Write in full)
full) (if not graduated)
From To
 EAST BAYUGAN CENTRAL ELEMENTARY 2009
ELEMENTARY
SCHOOL
PRIMARY EDUCATION 2002
6/24/2002 3/20/2009 Graduated 2009

SECNDARY EDUCATION (SPECIAL 2009

SECONDARY
BAYUGAN NATIONAL COMPREHENSIVE PROGRAM IN JOURNALISM-PIONEERING 2013 Graduated 2013
VOCATIONAL / HIGH SCHOOL CLASS)

AGUSAN DEL SUR COLLEGE Teacher Certificate Program 2022 PRESENT 18 units N/A
TRADE BACHELOR OF SCIENCE IN INFORMATION
MINDANAO STATE UNIVERSITY - MAIN 2013 2019
COURSE
COLLEGE
CAMPUS
TECHNOLOGY MAJOR IN MULTIMEDIA Graduated 2019
SYSTEMS

CARAGA STATE UNIVERSITY - MAIN MASTER OF SCIENCE IN INFORMATION 2021

GRADUATE STUDIES
CAMPUS TECHNOLOGY
PRESENT 27 units N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised
AL DATA SHEET
erience 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)

N/A

by naturalization
Pls. indicate country:

GAISANO EXTENSION
Street
TAGLATAWAN
Barangay
AGUSAN DEL SUR
Province
8502
GAISANO EXTENSION
Street
TAGLATAWAN
Barangay
AGUSAN DEL SUR
Province

8502

N/A

+639501011161

kimberlypalaran@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

N/A

Continue on separate sheet if neccesary

SCHOLARSHIP/ ACADEMIC
HONORS RECEIVED
 3RD HONORABLE MENTION

N/A

N/A

N/A

N/A

tinue on separate sheet if necessary)

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

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

(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
PHILIPPINE STATISTICS AUTHORITY - (Y/ N)

08/03/20
3/8/2020 09/30/21
9/30/2021 INFORMATION SYSTEMS ANALYST I PHILIPPINE IDENTIFICATION SYSTEM 26,578.80 SG 12 JOB ORDER N
(PHILSYS)
DEPARTMANT OF EDUCATION - DIVISION
01/03/22
1/3/2021 01/03/23
10/1/2021 TEACHER I 24,199.00 SG 11 PROVISIONAL N
OF AGUSAN DEL SUR

(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

STEP-2 REGISTRATION FOR THE PHILIPPINE IDENTIFICATION SYSTEM (PHILSYS) 06/17/21

6/17/2021 06/24/21
6/24/2021 64.0 TECHNICAL PHILIPPINE STATISTICS AUTHORITY

STEP-1 REGISTRATION FOR THE PHILIPPINE IDENTIFICATION SYSTEM (PHILSYS) 01/12/21

1/12/2021 01/14/21
1/14/2021 24.0 TECHNICAL PHILIPPINE STATISTICS AUTHORITY

DISTRICT CAPABILITY ACTIVITY ON CONDUCTING QUALITY ASSURANCE OF THE DEPED - DIVISION OF AGUSAN DEL SUR -
DEVEOPED LEARNING ACTIVITY SHEETS ON MATHEMATICS 03/28/22 03/30/22 24.0 TECHNICAL
ESPERANZA IV

(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)

DRAWING & PAINTING 2020 CBMS JINGLE CONTEST RUNNERS UP SUPREME STUDENT GOVERNMENT
CHAMPION MSU-COLLEGE OF INFORMATION TECHNOLOGY BALAGTASAN FILIPINO
DANCING N/A
LITERARY COMPETITION
SINGING 2ND PLACE MSU-COLLEGE OF NURSING POSTER MAKING CONTEST N/A

PLAYING INSTRUMENTS JUDGE IN MSU-COLLEGE OF BUSINESS AND ACCOUNTANCY LITERARY COMPETITION N/A

CLAY MODELING MS. CIT 2017 MSU-COLLEGE OF INFORMATION TECHNOLOGY N/A

CHAMPION REGIONAL SCHOOLS PRESS CONFERENCE DESKTOP PUBLISHING BAYUGAN
N/A N/A
CITY
N/A 2ND PLACE DIVISIONAL SCHOOLS PRESS CONFERENCE EDITORIAL CARTOONING N/A
(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
by any court or tribunal? YES ✘ NO
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? ________________________________
Finished Contract
________________________________
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
SOLEDAD M. RUBILLOS ESPERANZA, AGUSAN DEL SUR 0 9107421337 3.5 cm. X 4.5 cm
(passport size)

ELMER A. YUSON BAYUGAN CITY, AGUSAN DEL SUR 0 9292290202 With full and handwritten
name tag and signature over
printed name
JOFIL A. ISRAEL LAPU-LAPU, CEBU CITY 0 9758845127
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: PASSPORT

ID/License/Passport No.: P4096914B

Signature (Sign inside the box)

Date/Place of Issuance: 01-02-2020 / DFA BUTUAN 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