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

MIDDLE NAME DALINDING

3. DATE OF BIRTH
(mm/dd/yyyy)
4. PLACE OF BIRTH
03-28-1994 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
by naturalization
birth
PATADON ELEMENTARY SCHOOL If holder of dual citizenship, Pls. indicate country:

please indicate the details.

5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS N /A PUROK 4

Widowed House/Block/Lot No. Street
Separated N/A EAST PATADON
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 5'1 KIDAPAWAN NORTH COTABATO
City/Municipality Province
9406
8. WEIGHT (kg) 56kg ZIP CODE

9. BLOOD TYPE 'O' 18. PERMANENT ADDRESS N/A PUROK 4

House/Block/Lot No. Street
10. GSIS ID NO. N/A N/A EAST PATADON
Subdivision/Village Barangay
KIDAPAWAN NORTH COTABATO
11. PAG-IBIG ID NO. 121275076826
City/Municipality Province
12. PHILHEALTH NO. 17-201862166-0 ZIP CODE 9400

13. SSS NO. 34-9743833-4 19. TELEPHONE NO. N/A

14. TIN NO. 770-929-628 20. MOBILE NO. 9811060487

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) musa03281994@gmail.com
II. FAMILY BACKGROUND
DATE OF BIRTH
22. SPOUSE'S SURNAME MUSA 23. NAME of CHILDREN (Write full name and list all)
(mm/dd/yyyy)
FIRST NAME NASSER NAME EXTENSION (JR., SR) HANADEE MUSA 6/7/2013
N/A
MIDDLE NAME NENGA HAIFA MUSA 09-13-2015

OCCUPATION FARMER MUHADEE MUSA 09-26-2016

EMPLOYER/BUSINESS NAME N/A HANASHRA MUSA 5/9/2028

BUSINESS ADDRESS N/A MOHAIF MUSA 06-09-2021

TELEPHONE NO. N/A

24. FATHER'S SURNAME KUSAIN

FIRST NAME KUSAIN NAME EXTENSION (JR., SR)

N/A
MIDDLE NAME LIMATEC

25. MOTHER'S MAIDEN NAME

SURNAME BALIWAN

FIRST NAME SARAH

MIDDLE NAME BAGUMBAYAN (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND
HIGHEST
PERIOD OF LEVEL/ SCHOLARSHI
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE YEAR
ATTENDANCE UNITS P/ ACADEMIC
LEVEL (Write in full) GRADUAT
EARNED HONORS
(Write in full) ED
From To (if not RECEIVED
graduated)
ELEMENTARY PATADON ELEMENTARY SCHOOL PRIMARY EDUCATION 2001 2007 N/A 2007 N/A

VOCATIONAL
SECONDARY / PATADON HIGH SCHOOL HIGH SCHHOL 2007 2011 N/A 2011 N/A

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

UNIVERSITY OF SOUTHERN BACHELOR OF ART AND ISLAMIC

COLLEGE
TRADE COURSE 2011 2017 N/A 2017 N/A
MINDANAO STUDIES

GRADUATE STUDIES N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE April 8, 2024

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

BOARD OF PROFESSIONAL TEACHER 82.4 03/27/2022 KIDAPAWAN CITY 192349 2022-2025

(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 SERVICE
28. INCLUSIVE DATES SALARY/ JOB/ PAY
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)

4/3/2024 4/4/2024 SUBSTITUTE TEACHER DEPARMENT OF EDUCATION 27,000.00 N/A SUBSTITUTE Y

08/29/23 10/11/23 SUBSTITUTE TEACHER DEPARMENT OF EDUCATION 27,000.00 N/A SUBSTITUTE Y

DEPARTMENT OF INTERIOR AND LOCAL CONTRACT OF

1/10/2020 12-13-2020 CONTRACT TRACER
GOVERNMENT
18.5K N/A
SERVICE
Y

(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 8, 2024

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

(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) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To

Gamified quizezz and lesson with quizizz Al 08/12/23 08/12/23 2.0 MANAGERIAL Edtech Teacher Traning Center

FOOD safety and product label 08/14/23 08/14/23 8.0 TECHNICAL

DTI
DEPED TEACHING AND NON TEACHING COMPETENCIES AND STANDARD
2/5/2023 2/5/2023 8.0 MANAGERIAL
QUALIFICATION. JOHN PHILIP ORDENES ,MAED
TECHNICAL EDUCATION SKILLS AND
SKILL ENHANCEMENTON BREAD AND PASTRY 10-24-2022 10-24-2022 40.0 TECHNICAL
DEVELOPMENT AUTHORITY

PABASA SA NUTRISYON ACTIVITY 10/24/2022 10/24/2022 8.0 TECHNICAL

CITY HEALTH OFFICE

FOOD AND BEVERAGE SERVICE NCII 5/20/2019 5/20/2019 336.0 teachnical

Edtech Teacher Traning Center

(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)

BAKING SKILLS ENHANCEMENT ON BREAD AND PASTRY BANGSAMORO WOMENS

(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 8, 2024

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
JACINTA PASCUAL MANONGOL KIDAPAWAN 9187632130 3.5 cm. X 4.5 cm
(passport size)

FATMA T. SADANG PATADON EAST, KIDAPAWAN CITY 9363103969 With full and handwritten
name tag and signature over
printed name
SARAH EMAN PATADON EAST 9120613397
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: PRC ID

ID/License/Passport No.: 192349

Signature (Sign inside the box)
APRIL 8, 2024
Date/Place of Issuance: KIDAPAWAN 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