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 AMPER
NAME EXTENSION (JR., SR)
FIRST NAME JONALYN

MIDDLE NAME DIA-ON

3. DATE OF BIRTH
(mm/dd/yyyy) 1/19/1992 16. CITIZENSHIP

4. PLACE OF BIRTH SINUDA, KITAOTAO, BUKIDNON If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX FEMALE

17. RESIDENTIAL ADDRESS

6 CIVIL STATUS MARRIED
House/Block/Lot No. Street
SITIO KABALANSIHAN SINUDA
Subdivision/Village Barangay
KITAOTAO BUKIDNON
7. HEIGHT (m) 4"11
City/Municipality Province
8. WEIGHT (kg) 40 ZIP CODE 8716

18. PERMANENT ADDRESS

9. BLOOD TYPE O
House/Block/Lot No. Street
SITIO KABALANSIHAN SINUDA
10. GSIS ID NO.
Subdivision/Village Barangay
KITAOTAO BUKIDNON
11. PAG-IBIG ID NO. N/A
City/Municipality Province

12. PHILHEALTH NO. 15-252245881-8 ZIP CODE 8716

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

14. TIN NO. 481-828-672-000 20. MOBILE NO. 09361413668/09751134155

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) amperlynn1992@gmail.com

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

22 SPOUSE'S SURNAME AMPER 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

NAME EXTENSION (JR., SR) JHON DAVE D. AMPER

FIRST NAME DAVID 10/12/2010
IVAN DAVE D. AMPER
MIDDLE NAME EWAS 11/3/2015
KIAN SHIAN D. AMPER
OCCUPATION FARMER 11/4/2019

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24 FATHER'S SURNAME DIA-ON

NAME EXTENSION (JR., SR)
FIRST NAME JOSE

MIDDLE NAME DAY-AS

25 MOTHER'S MAIDEN NAME

SURNAME PANIA

FIRST NAME ROSILDA

MIDDLE NAME BOLAO (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND

26 PERIOD OF ATTENDANCE HIGHEST LEVEL/ SCHOLARSHIP/

NAME OF SCHOOL YEAR
BASIC EDUCATION/DEGREE/COURSE UNITS ACADEMIC
LEVEL (Write in EARNED
GRADUATED
HONORS
(Write in full)
full) (if not graduated) RECEIVED

From To

ELEMENTARY SINUDA CENTRAL ELEMENTARY SCHOOL 2005

SECONDARY
VOCATIONAL / SINUDA NATIONAL HIGH SCHOOL 2009

TRADE
COURSE
COLLEGE QUEZON INSTITUTE OF TECHNOLOGY INC.(QIT) 2019

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE
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 80.2 10/2/2022 CAGAYAN DE ORO CITY 1972863

Jan. 19/26

(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
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

28 (Y/ N)

From To

NONE

(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

KMMKM ORGANIZATION FOR WOMENS Yr2018 Yr2023 BOARD MEMBER

BARANGAY SERVICE POINT OFFICER (BSPO) Yr2022 Yr2023 VOLUNTEER

APOLLO 1 READING CENTER Yr 2023 PRESENT VOLUNTEER TEACHER

(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

INDIGENOUS KNOWLEDGE SYSTEM AND PRACTICES (IKSP) Jan. 5, 2023 Jan. 7, 2023 24 hours FEMMATRICS, SINUDA

10 Day Weekend Training -Workshop on ICT-Based Integration in Education for Teacher-

Dec. 18, 2023 Jan. 28, 2023 80 hours
Applicant ARIEL B. MONTECALBO, PhD

(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)

COOKING N/A N/A

DANCING N/A N/A

SINGING N/A N/A

CLEANING N/A N/A

GARDENING N/A 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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
________________________________
N/A

35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
N/A
________________________________
b. Have you been criminally charged before any court?
If YES, give details:
________________________________
Date Filed: N/A
________________________________
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:
________________________________
N/A
________________________________
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? ________________________________
N/A
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? N/A
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: N/A
39. Have you acquired the status of an immigrant or permanent resident of another country?
If YES, give details (country):
N/A
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: MATIGSALUG
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
MONTE A. GAWILAN P2, SINUDA KITAOTAO BUKIDNON (passport size)

With full and handwritten

ALEXANDER P. CEPEDA SALAWAGAN QUEZON BUKIDNON name tag and signature over
printed name

Computer generated
EDWIN P. ABUCAYAN KITAOTAO BUKIDNON 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: PRC LICENSE

ID/License/Passport No.: 19172863

Signature (Sign inside the box)

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