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) N/A
FIRST NAME JUAN
MIDDLE NAME SANTOS
3. DATE OF BIRTH
(mm/dd/yyyy) 09/30/1974 16. CITIZENSHIP
✘ Filipino Dual Citizenship

by birth by naturalization
4. PLACE OF BIRTH Malaybalay City, Bukidnon If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX
Male ✘ Female
17. RESIDENTIAL ADDRESS BLK 3, LOT15 N/A
6 CIVIL STATUS Single ✘ Married House/Block/Lot No. Street
Widowed Separated NHA P3 CASISANG
Other/s:
Subdivision/Village Barangay
MALAYBALAY CITY BUKIDNON
7. HEIGHT (m) 1.58
City/Municipality Province
8. WEIGHT (kg) 60 kg ZIP CODE 8700

18. PERMANENT ADDRESS BLK 3, LOT 15 N/A

9. BLOOD TYPE A
House/Block/Lot No. Street
NHA P3 CASISANG
10. GSIS ID NO. 2005520239
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1820-0089-5412 MALAYBALAY CITY BUKIDNON

City/Municipality Province

12. PHILHEALTH NO. 15-0500232406 ZIP CODE 8700

13. SSS NO. 08-111-0333-2 19. TELEPHONE NO. 088-314-0837

14. TIN NO. 190-981-355 20. MOBILE NO. 09272318120/09463668448

15. AGENCY EMPLOYEE NO. 4989797 21. E-MAIL ADDRESS (if any) ayessa@yahoo.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME DELA CRUZ 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME VILMA N/A KATRIN A. DELA CRUZ 1/1/2022

MIDDLE NAME AUNOR

OCCUPATION TEACHER

EMPLOYER/BUSINESS NAME DEPARTMENT OF EDUCATION-DIVISION OF MALAYBALAY CITY

BUSINESS ADDRESS P-6 CASISANG MALAYBALAY CITY

TELEPHONE NO. N./A

24. FATHER'S SURNAME DELA CRUZ

NAME EXTENSION (JR., SR)
FIRST NAME ALJUR JR.

MIDDLE NAME FERNANDEZ

25. MOTHER'S MAIDEN NAME

SURNAME ABRENICA

FIRST NAME KYLIE

MIDDLE NAME PADILLA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY SUMPONG ELEMENTARY SCHOOL ELEMENTARY 1981 1987 GRADUATED 1987 N/A

VOCATIONAL
SECONDARY / BUKIDNON NATIONAL HIGH SCHOOL HIGH SCHOOL 1987 1993 GRADUATED 1991 N/A

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

TRADE BACHELOR OF SCIENCE IN
COLLEGE
COURSE BUKIDNON STATE COLLEGE 1991 1995 GRADUATED 1995 N/A
ACCOUNTANCY
GRADUATE STUDIES 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

CAREER SERVICE PROFESSIONAL 80.5 1/12/1996 Bukidnon National High School N/A N/A

R.A 1080 (PROFESSIONAL TEACHER) 90.5 1/12/2005 CAGAYAN DE ORO CITY 123546 9/30/2025

P.D 907 (HONOR GRADUATE) N/A N/A BUKIDNON STATE UNIVESITY 209586757 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
(Y/ N)
Department of Education-Division of
3/5/2019 PRESENT TEACHER I 27000.00 11-01 Permanent Y
Malaybalay City
CITY GOVERNMENT OF MALAYBALAY
2/15/2015 2/28/2018 ADMINISTRATIVE AIDE 10000.00 00-0 JOB ORDER N
CITY
Department of Education-Division of
2/15/2013 6/30/203 TEACHER I 25439.00 11-1 SUBSTITUTE Y
Malaybalay City

(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

2018-omnibus rules on appointment and other human resorce action (oraohra) 2/5/2020 2//7/2020 36 hrs Technical CIVIL SERVICE COMMISSION

QUALITY MANAGEMENT SYSTEM AWARENESS: AN ORIENTATION WORKSHOP 1/23/2020 1/23/2020 8 HRS Technical Department of Education-DIVISION
MALAYBALAY CITY
ORIENTATION ON THE PROGRAM TO INSTITUTIONALIZE MERITOCRACY AND
9/30/2019 9/30/2019 8 HRS Technical Department of Education-DIVISION
EXCELLENCE ON HUMAN RESOURCE MANAGEMENT (PRIME-HRM)
MALAYBALAY CITY

RISK BASED AUDIT METHODOLOGY 7/25/2014 7/26/2014 16 HRS SUPERVISORY RURAL BANKER ASSOCIATION OF THE
PHILIPPINES

BASIC COOPERATIVE BANKING COURSE 8/11/1997 10/18/1997 80 HRS Technical BANGKO SENTRAL NG PILIPINAS

(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)

READING CERTIFICATE OF RECOGNITION- AS FACILITATOR DURING ICON n/a

PLAQUE OF RECOGNITION-AS RESOURCE SPEAKER TITLE HOLDERS FORUM

(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? ________________________________
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
VILMA A. SANTOS MALAYBALAY CITY 09177067785 3.5 cm. X 4.5 cm
(passport size)

ROBIN L. PADILLA MALAYBALAY CITY 09268393295 With full and handwritten

name tag and signature over
printed name
ERWIN B. TULFO MALAYBALAY CITY 09656559104
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: umid

ID/License/Passport No.: crn-000-8111-0333-2

Signature (Sign inside the box)

Date/Place of Issuance: 11/16/2018/ malaybalay 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