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

MIDDLE NAME DIÑO

3. DATE OF BIRTH
Wednesday, March 8, 1995 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH MANILA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS #07 PAUIG

House/Block/Lot No. Street
Separate
Widowed CENTRO 1
Other/s: d Subdivision/Village Barangay
ENRILE CAGAYAN
7. HEIGHT (m) 1.56
City/Municipality Province
8. WEIGHT (kg) 53 ZIP CODE 3501

18. PERMANENT ADDRESS #07 PAUIG

9. BLOOD TYPE O
House/Block/Lot No. Street
CENTRO 1
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A ENRILE CAGAYAN

City/Municipality Province

12. PHILHEALTH NO. 06-250166358-7 ZIP CODE 3501

13. SSS NO. 01-2491174-5 19. TELEPHONE NO. N/A

14. TIN NO. 468-228-092-000 20. MOBILE NO. 09555296865

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) richiedinobaltazar1995@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)

FIRST NAME N/A

NAME EXTENSION (JR., SR) 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 BALTAZAR

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

MIDDLE NAME GAFFUD

25. MOTHER'S MAIDEN NAME

SURNAME DIÑO

FIRST NAME NORA

MIDDLE NAME ROMERO (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

ELEMENTARY MUZON PABAHAY ELEMENTARY SCHOOL ELEMENTARY 2001 2007 GRADUATE 2007 N/A

SECONDARY OUR LADY OF SNOWS ACADEMY SECONDARY EDUCATION 2007 2011 GRADUATE 2011 N/A

VOCATIONAL / TRADE
COURSE
N/A N/A N/A N/A N/A N/A N/A

BACHELOR OF SCIENCE IN
COLLEGE CAGAYAN STATE UNIVERSITY
ENTREPRENEURSHIP
2011 2015 GRADUATE 2015 N/A

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A 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 TEACHERS 86.2 10/2/2022 TUGUEGARAO, CITY 1963676 8/3/2026

(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
DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) POSITION TITLE MONTHLY STATUS OF
(Write in SALARY
applicable)& STEP
APPOINTMENT
(Write in full/Do not abbreviate) (Format "00-0")/
full/Do not abbreviate) INCREMENT
From To
(Y/ N)
CONTRACTUA
5/6/2017 04/30/2020 SHS TEACHER SAINT PHILOMENE OF ALCALA, INC. 9000.00 N/A N
L

(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
INCLUSIVE DATES OF Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To
TECHNICAL EDUCATION AND SKILLS
NCII - TILE SETTING 9/1/2023 01/24/2023 88 HOURS TECHNICAL
DEVELOPMENT AUTHORITY (TESDA)
TUGUEGARAO TRAINING AND ASSESSMENT
CERTIFICATE OF SPECIALIZED TRAINING (ICT) 7/11/2022 11/18/2022 80 HOURS TECHNICAL
CENTER

PEAC 2018 IN - SERVICE TRAINING FOR SENIOR HIGH SCHOOL TEACHERS 4/5/2018 6/5/2018 24 HOURS MANAGERIAL PRIVATE EDUCATION ASSISSTANCE COMMITTEE

IN-SERVICE TRAINING FOR FACULTY AND STAFF 05/28/2018 1/6/2018 40 HOURS MANAGERIAL SAINT PHILOMENE OF ALCALA, INC.

TRAINING-WORKSHOP ON K12 PEDAGOGICAL APPROACHES 04/26/2018 04/29/2018 32 HOURS MANAGERIAL F.L. VARGAS COLLEGE

(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)
NATIONAL BOOK DEVELOPMENT BOARD
AUTHOR/WRITER REGISTERED WRITER - CERTIFICATE OF REGISTRATION
(NBDB)
CSU ANDREWS - ATHENA PERFORMING ARTS
DANCER/CHOREOGRAPHER SOCIO-CULTURAL AWARDEE
BUREAU (APAB)

(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? RESIGNATION
________________________________
________________________________
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
MRS. ROSELILY S. TORRIJOS SAINT PHILOMENE OF ALCALA, INC. 927 643 9317 4.5 cm. X 3.5 cm
(passport size)

Computer generated
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: NATIONAL ID

ID/License/Passport No.: 4657-1206-9528-9167

Signature (Sign inside the box)

Date/Place of Issuance: TUGUEGARAO CITY, CAGAYAN

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