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 OBREGOSO
NAME EXTENSION (JR., SR)
FIRST NAME PLIERE JHANE

MIDDLE NAME COLINAYO

3. DATE OF BIRTH
(mm/dd/yyyy) 07/27/1996 16. CITIZENSHIP

4. PLACE OF BIRTH BASEY,SAMAR If holder of dual citizenship, Pls. indicate country:

please indicate the details.
5. SEX

17. RESIDENTIAL ADDRESS PUROK II

6 CIVIL STATUS
House/Block/Lot No. Street
SERUM
Subdivision/Village Barangay
BASEY SAMAR
7. HEIGHT (m) 1.4
City/Municipality Province
8. WEIGHT (kg) 40 ZIP CODE 6720
18. PERMANENT ADDRESS PUROK II
9. BLOOD TYPE O
House/Block/Lot No. Street
SERUM
10. GSIS ID NO. NONE
Subdivision/Village Barangay
BASEY SAMAR
11. PAG-IBIG ID NO. NONE
City/Municipality Province

12. PHILHEALTH NO. NONE ZIP CODE 6720

13. SSS NO. NONE 19. TELEPHONE NO. NONE

14. TIN NO. 728-128-715 20. MOBILE NO. 09095763448

15. AGENCY EMPLOYEE NO. NONE 21. E-MAIL ADDRESS (if any) camline04@gmail.com
II. FAMILY BACKGROUND
DATE OF BIRTH
22. SPOUSE'S SURNAME NONE 23. NAME of CHILDREN (Write full name and list all)
(mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME NONE

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME OBREGOSO

NAME EXTENSION (JR., SR)
FIRST NAME PANCHO NONE

MIDDLE NAME OLFINDO

25. MOTHER'S MAIDEN NAME

SURNAME COLINAYO

FIRST NAME NENITA

MIDDLE NAME ORTILLO (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
GRADUAT
(Write in full) ED
HONORS
full) (if not graduated) RECEIVED
From To

ELEMENTARY SERUM ELEMENTARY SCHOOL ELEMENTARY EDUCATION 2003 2009 N/A 2009 HONORS

SECONDARY BASEY NATIONAL HIGH SCHOOL HIGH SCHOOL 2009 2013 N/A 2013 NONE
VOCATIONAL /
NONE
TRADE COURSE
COLLEGE LEYTE NORMAL UNIVERSITY BACHELOR OF ELEMENTARY EDUCATION 2013 2017 N/A 2017 ESGP-PA

GRADUATE STUDIES NONE

(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 TEACHERS 75.0 9/24/2017 TACLOBAN CITY 1574247 7/27/2023

(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)

02/24/2022 5/8/2022 SUBSTITUTE TEACHER RAWIS ELEMENTARY SCHOOL 25,439.00 SG-11 SUBSTITUTE Y

09/17/2021 12/14/2021 SUBSTITUTE TEACHER AGIMIT ELEMENTARY SCHOOL 23,877.00 SG-11 SUBSTITUTE Y

10/15/2018 08/20/2021 ALS LITERACY FACILITATOR ALS BASEY I DISTRICT 1,999.00 N/A Contractual Y

06/05/2018 08/03/2018 SUBSTITUTE TEACHER SERUM ELEMENTARY SCHOOL 20,179.00 SG-11 SUBSTITUTE Y

04/01/2018 06/04/2018 VOLUNTEER TEACHER SERUM ELEMENTARY SCHOOL NONE N/A N/A Y

(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

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

District Roll-Out On Philippine Professional Standards for Teachers

1/29/2019 1/31/2019 24.0 Technical Basey I District
(PPST) And Result-Based Performance Management System (RPMS)

2018 Regional Indigeneous People Education Summit 10/30/2018 10/30/2018 8.0 Technical Basey Municipal Gymnasium

Enhancement of Kindergarten and Grade I Teachers Pedagogical

Skills in Teaching Beginning Reading and Orientation On 6/22/2018 6/24/2018 24.0 Technical Basey I District
Administration of the New PHIL-IRI

TRAINING OF CAMPUS JOURNALISM ADVISERS AND WRITERS 2/24/2018 2/26/2018 24.0 Technical Basey I District

ICT COMPUTER LITERACY TRAINING-WORKSHOP 10/21/2017 12/9/2017 120.0 Technical Leyte Normal University

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33. ASSOCIATION/ORGANIZATION
(Write in full)
(Write in full)

COMPUTER LITERATE NONE NONE

TEACHING

READING

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?
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
JAY G. ABIA CATBALOGAN, CITY 9177063072 (passport size)

ELEGARIO Q. OCDOL JR. BASEY, SAMAR 9778094015 With full and handwritten
name tag and signature over
printed name
RUEL B. GACUTNO BASEY, SAMAR NONE
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
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable

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.: 1574247

Signature (Sign inside the box)

Date/Place of Issuance: 11/27/2017 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