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 DELA CRUZ
NAME EXTENSION (JR., SR)
FIRST NAME JUAN N/A

MIDDLE NAME MACABUGTO

3.
DATE OF BIRTH 04/17/1992 16. CITIZENSHIP
(mm/dd/yyyy)
✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH WEST POBLACION, BALO-I If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female
17. RESIDENTIAL ADDRESS N/A GAWAD KALINGA
6 CIVIL STATUS Single ✘ Married
Widowed Separated House/Block/Lot No. Street
TAG-IBO DALIPUGA
Other/s:
Subdivision/Village Barangay
ILIGAN CITY LANAO DEL NORTE
7. HEIGHT (m) 1.78
City/Municipality Province
8. WEIGHT (kg) 73 ZIP CODE 9200

18. PERMANENT ADDRESS N/A SAWMILL

9. BLOOD TYPE O
House/Block/Lot No. Street
PUROK 2 WEST POBLACION
10. GSIS ID NO. 200-5040-471
Subdivision/Village Barangay
BALO-I LANAO DEL NORTE
11. PAG-IBIG ID NO. 1211-2116-4776
City/Municipality Province
12. PHILHEALTH NO. 1520-1926-9935 ZIP CODE 9217

13. SSS NO. 0824-8099-66 19. TELEPHONE NO. 225-2798

14. TIN NO. 474-096-673 20. MOBILE NO. 0909-999-9999

15. AGENCY EMPLOYEE NO. 4773794 21. E-MAIL ADDRESS (if any) juan.macabugto@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) N/A
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 PANDAPATAN
NAME EXTENSION (JR., SR)
FIRST NAME TANNY N/A

MIDDLE NAME DIRIPOSEN

25. MOTHER'S MAIDEN NAME

SURNAME MENDEZ

FIRST NAME LENIE

MIDDLE NAME GALUA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

BASIC EDUCATION/DEGREE/COURSE HIGHEST LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
NAME OF SCHOOL UNITS ACADEMIC
LEVEL (Write in full) EARNED
GRADUATED
HONORS
(Write in full)
(if not graduated) RECEIVED
From To

ELEMENTARY LUINAB ELEMENTARY SCHOOL PRIMARY EDUCATION 1999 2005 N/A 2005 WITH HONORS

WITH
SECONDARY ILIGAN CITY NATIONAL HIGH SCHOOL HIGH SCHOL 2005 2009 N/A 2009
HONORS
VOCATIONAL /TRADE SANDUGO COMPUTER AND ALTERNATIVE WITH
SHORT COURSE 2015 2015 N/A 2015
COURSE LEARNING SYSTEM HONORS

COLLEGE MINDANAO STATE UNIVERSITY-MAIN CAMPUS BACHELOR OF ARTS IN FILIPINO 2009 2013 N/A 2013 N/A

MASTER OF ARTS IN FILIPINO MAJOR IN BEST

GRADUATE STUDIES MINDANAO STATE UNIVERSITY-MAIN CAMPUS 2016 2018 N/A 2018
LINGUISTICS THESIS
(Continue on separate sheet if necessary)

SIGNATURE DATE 06/28/2021

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 BARANGAY ELIGIBILITY / EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
DRIVER'S LICENSE CONFERMENT
Validity

LICENSURE EXAMINATION FOR TEACHERS 82.2 01/24/2014 LAPASAN, CAGAYAN DE ORO CITY 1350073 04/17/2023

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

DEPARTMENT OF EDUCATION - DIVISION

6/1/2016 PRESENT TEACHER I 22,600.00 11-1 PERMANENT YES
OF ILIGAN CITY
6/1/2014 05/31/2016 TEACHER I IBN SIENA INTEGRATED SCHOOL FOUNDATION 10,000.00 5-1 CONTRACTUAL NO

6/1/2013 03/30/2014 TEACHER I WEST EASTERN PHILIPPINE COLLEGE INC. 4,500.00 2-1 CONTRACTUAL NO
DEPARTMENT OF EDUCATION - DIVISION
05/01/2010 08/15/2020 TEACHER I 21,356.00 11-1 SUBSTITUTE YES
OF ILIGAN CITY

(Continue on separate sheet if necessary)

SIGNATURE 06/28/2021

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 (Write INCLUSIVE DATES
29.
in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

NATIONAL YOUTH COMMISSION 08/12/2018 08/13/2018 20.0 FACILITATOR

ILIGAN YOUTH AFFAIRS 10/24/2017 10/26/2017 30.0 FACILITATOR

(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 ( Managerial/ CONDUCTED/ SPONSORED BY
ATTENDANCE (mm/dd/yyyy) NUMBER OF HOURS
(Write in full) Supervisory/ (Write in full)
Technical/etc)
From To

INTERNATIONAL WEBINAR SMART LEARNING METHOD AND FLIPPED LEARNING 01/21/2021 01/21/2021 3.0 TECHNICAL UNIVERSITAS MUHAMMADIYAH, INDONESIA

GENDER AND DEVELOPMENT TRAINING SEMINAR 12/17/2020 12/19/2020 24.0 TECHNICAL DALIPUGA NATIONAL HIGH SCHOOL

IN-SERVICE TRAINING FOR TEACHERS 2020 12/14/2020 12/16/2020 24.0 TECHNICAL DALIPUGA NATIONAL HIGH SCHOOL
PAMBANSANG SAMAHAN SA LINGGUWSITIKA AT
SPECIAL COURSE ON TRANSLATION 08/22/2020 09/09/2020 11.0 TECHNICAL
LITERATURANG FILIPINO

RESILIENT YOUTH LEADERSHIP SUMMIT 08/24/2020 08/25/2020 16.0 TECHNICAL DHAKA OIC YOUTH CAPITAL 2020

SENTRO NG WIKA AT KULTURA/MINDANAO STATE

ANG WIKANG FILIPINO SA PAG-AARAL NG KALINANGAN AT KASAYSAYANG BAYAN 08/26/2020 08/26/2020 3.0 TECHNICAL
UNIVERSITY

REGIONAL CONSORTIUM ON FLEXIBLE LEARNING 07/09/2020 07/31/2020 30.0 TECHNICAL COMMISSION ON HIGHER EDUCATION-10

INTERNATIONAL WEBINAR ON EDUCATIONAL TECHNOLOGY TO SUPPORT ONLINE SOUTHEAST ASIA MINISTRIES OF EDUCATION
07/17/2020 07/17/2020 3.0 TECHNICAL
LEARNING ORGANIZATION
THE ACTION RESEARCH METHODOLOGY CANDY STORE: INNOVATIVE APPROACHES
07/22/2020 07/22/2020 3.0 TECHNICAL DE LA SALLE UNIVERSITY LIDER
FOR DATA GATHERING

STATISTICAL METHODS FOR LINGUISTICS 07/11/2020 07/11/2020 3.0 TECHNICAL DE LA SALLE UNIVERSITY LIDER

MULTI-LAYERED ACTIVITIES FOR AN ONLINE AND TRADITIONAL CLASSROOM 06/06/2020 06/06/2020 3.0 TECHNICAL UNIVERSITY OF INDONESIA

HOW TO LEARN A LANGUAGE 05/28/2020 06/04/2020 24.0 TECHNICAL OPEN UNIVERSITY, UK

UNDERSTANDING LANGUAGE AND LEARNING 05/25/2020 06/02/2020 10.0 TECHNICAL OPEN UNIVERSITY, UK

SUPPORTING ADOLESCENT LEARNERS: SOCIAL AND EMOTIONAL WELLBEING 05/29/2020 06/01/2020 6.0 TECHNICAL GRIFFITH UNIVERSITY/FUTURE LEARN

UNIVERSITY OF THE PHILIPPINES OPEN

UNDERSTANDING THE CHILD BETTER 03/01/2020 04/30/2020 16.0 TECHNICAL
UNIVERSITY
UNIVERSITY OF THE PHILIPPINES OPEN
TEACHING AND LEARNING WITH MODERN ICTS 03/01/2020 04/30/2020 16.0 TECHNICAL
UNIVERSITY
UNIVERSITY OF THE PHILIPPINES OPEN
INTRODUCTION TO TECHNOLOGY FOR TEACHING AND LEARNING 03/01/2020 04/30/2020 16.0 TECHNICAL
UNIVERSITY
UNIVERSITY OF THE PHILIPPINES OPEN
BLENDED TEACHING AND LEARNING USING OERS 03/01/2020 04/30/2020 16.0 TECHNICAL
UNIVERSITY

FISIP IDEAS MATTER 6.0 11/01/2019 11/04/2019 43.0 TECHNICAL UNIVERSITY OF AIRLANGGA, INDONESIA

MINISTRY OF EDUCATION AND CULTURE,

WORLD HERITAGE CAMP INDONESIA 2019 10/20/2019 10/27/2019 80.0 TECHNICAL
INDONESIA
NATIONAL INSTITUTE OF DEVELOPMENT AND
CREATIVE AND INNOVATIVE ECONOMY 2019 06/30/2019 07/07/2019 80.0 TECHNICAL
ADMINISTRATION, THAILAND
VIII. OTHER INFORMATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full) (Write in full)

WRITING INDONESIAN LANGUAGE AND CULTURE STUDY PROGRAM WITH HONORS EQUAL ACCESS INTERNATIONAL PHILIPPINES
STUDENT LEAGUE FOR ACADEMIC
READING SCHOOL OUTSTANDING TEACHER
ADVANCEMENT AND PROGRESS
BIDLISIW: COLLEGE OF SOCIAL SCIENCES
ORGANIZING COMMENDABLE DEMONSTRATOR
AND HUMANITIES PUBLICATION
LANGUAGE ENTHUSIAST MASTERS BEST THESIS AWARDEE DALIPUGA NHS FACULTY CLUB

COLLABORATIVE DALIPUGA NHS SCHOOL PAPER

WATCHING SAMAHAN NG MAG-AARAL NG FILIPINO

SEARCHING LANAO NORTE STUDENT ASSOCIATION

(Continue on separate sheet if necessary)

SIGNATURE DATE 06/28/2021

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:
________________________________
N/A
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? ________________________________
END OF 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
Edna M. Manginsay Suarez, Iligan City 0919-499-2725 4.5 cm. X 3.5 cm
(passport size)

Cristy May U. Sistona Pugaan, Iligan City 0947-033-8870

Computer generated
or photocopied picture
Ritchel D. Jimenez Luinab, Iligan City 0951-029-1048 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: PRC ID

ID/License/Passport No.: 1300573 Signature (Sign inside the box)
06/28/2021
Date/Place of Issuance: 05/05/2014-CAGAYAN DE ORO 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