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 PANELO

FIRST NAME RICA

MIDDLE NAME ABANDO

3. DATE OF BIRTH
8/10/1999 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH AGOO, LA UNION If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS

Widowed House/Block/Lot No. Street

Separate
SAN PEDRO
Other/s: d
Subdivision/Village Barangay
AGOO LA UNION
7. HEIGHT (m) 1.50
City/Municipality Province
8. WEIGHT (kg) 53 ZIP CODE 2504

18. PERMANENT ADDRESS

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

11. PAG-IBIG ID NO. N/A AGOO LA UNION

City/Municipality Province

12. PHILHEALTH NO. 05-0258863183 ZIP CODE 2504

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

14. TIN NO. N/A 20. MOBILE NO. 09121135765

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) ricapanelo123@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)
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME PANELO

FIRST NAME EDGAR

MIDDLE NAME RIVERA

25. MOTHER'S MAIDEN NAME

SURNAME ABANDO

FIRST NAME FE

MIDDLE NAME GAYO (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
(Write in full) HONORS
full) (if not graduated) RECEIVED
From To

ELEMENTARY CUBAL ELEMENTARY SCHOOL N/A 2006 2012 2012 N/A

PRESIDENT ELPIDIO QUIRINO NATIONAL HIGH SCIENCE TECHNOLOGY ENGINEERING and WITH
SECONDARY /
VOCATIONAL SCHOOL MATHEMATICS 2012 2018 2018
HONOR

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

TRADE
DON MARIANO MARCOS MEMORIAL STATE BACHELOR OF SECONDARY EDUCATION
COURSE
COLLEGE
UNIVERSITY - SOUTH LA UNION CAMPUS MAJOR IN FILIFIPNO
2018 2022 2022 N/A

GRADUATE STUDIES 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

CAREER SERVICE/ RA 1080 (LET PASSER) 82.6 3/19/2023 PRC BAGUIO 2098418 10/8/2026

(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
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)
MUNICIPAL SOCIAL WELFARE AND
1/9/2022 PRESENT DAY CARE TEACHER 5,OOO N/A CONTRACTUAL Y
DEVELOPMENT OFFICE

(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
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
ORIENTATION OF INTERNATIONAL ASSESSMENT TEAMS/BRGY. COUNCIL FOR
PROTECTION OF CHILDREN(BCPC) MEMBERS ON THE EARLY CHILDHOOD CARE AND 01/25/2024 01/25/2024 8.0 MANAGERIAL LOCAL GOVERNMENT UNIT
DEVELOPMENT GUIDELINES
CAMP COORDINATION AND CCAMP MANAGEMENT TRAINING 09/20/2022 09/20/2022 24.0 MANAGERIAL
LOCAL GOVERNMENT UNIT

FIRST AGOO EDUCATIONAL SUMMIT 10/13/2023 10/13/2023 8.0 MANAGERIAL

LOCAL GOVERNMENT UNIT
7'TH PROVINCIAL CONVENTION FOR LA UNION SERVICES PROVIDERS AND CHILD
04/19/2023 04/19/2023 24.0 MANAGERIAL
DEVELOPMENT WORKERS LOCAL GOVERNMENT UNIT

STRESS MANAGEMENT SEMINAR CUM YEAR-END MUDCWA AGOO CONFERENCE HALL 1/12/2022 1/12/2022 8.0 MANAGERIAL
LOCAL GOVERNMENT UNIT

ORGANIZATIONAL LEADERSHIP AND MANAGEMENT TRAINING 11/8/2022 08/13/2022 24.0 MANAGERIAL

GOSHEN SEED FARM ORGANIZATION

USING EDUCATIONAL TECHNOLOGY IN THE ENGLISH LANGUAGE CLASSROOM 1/30/2024 1/30/2024 8.0 SUPERVISORY
TESDA

(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)

GOOD COMMUNICATOR N/A N/A

BASIC COMPUTER LITERACY N/A N/A

READING N/A N/A

N/A N/A 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 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 ✘ NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘ NO
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? ________________________________
________________________________
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
BIMBO ESTOCAPIO HONEYMOON ROAD BAGUIO CITY 9162030810 4.5 cm. X 3.5 cm
(passport size)

RICA FANGON SAN ANTONINO, AGOO, LA UNION 9074407195

Computer generated
or photocopied picture
MA. LIZA CABILATAZAN SAN AGUSTIN EAST, AGOO, LA UNION 9954010558 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.: 2098418

Signature (Sign inside the box)

Date/Place of Issuance: AUGUST 17, 2023

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