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 BALACANO
NAME EXTENSION (JR., SR) NONE
FIRST NAME VERONICA

MIDDLE NAME JULIAN

3. DATE OF BIRTH
12/15/1989 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
✘
by by
birth naturalization
4. PLACE OF BIRTH STO. TOMAS, SAGUDAY, QUIRINO If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS PUROK BAGONG SILANG
House/Block/Lot No. Street
Separate
Widowed STO. TOMAS,
Other/s: d Subdivision/Village Barangay
7. HEIGHT (m) 1.63m SAGUDAY, QUIRINO
City/Municipality Province
8. WEIGHT (kg) 65 kg. ZIP CODE 3402

9. BLOOD TYPE O+
18. PERMANENT ADDRESS PUROK BAGONG SILANG
House/Block/Lot No. Street
10. GSIS ID NO. 2005857954 STO. TOMAS,
Subdivision/Village Barangay
SAGUDAY, QUIRINO
11. PAG-IBIG ID NO. 1210-6712-3725
City/Municipality Province

12. PHILHEALTH NO. 06-050107458-9 ZIP CODE 3402

13. SSS NO. 01-2039082-3 19. TELEPHONE NO. -NONE-

14. TIN NO. 406-918-102-000 20. MOBILE NO. 09050476279

15. AGENCY EMPLOYEE NO. 5270944 21. E-MAIL ADDRESS (if any) nica.gia25@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME NONE 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) NONE
FIRST NAME NONE NONE

MIDDLE NAME NONE NONE NONE

OCCUPATION NONE NONE NONE

EMPLOYER/BUSINESS NAME NONE NONE NONE

BUSINESS ADDRESS NONE NONE NONE

TELEPHONE NO. NONE NONE NONE

24. FATHER'S SURNAME BALACANO

NAME EXTENSION (JR., SR)
FIRST NAME MANUEL NONE

MIDDLE NAME PASCUAL

25. MOTHER'S MAIDEN NAME

SURNAME JULIAN

FIRST NAME MARINA

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

STO. TOMAS ELEMENTARY SCHOOL

ELEMENTARY GRADE 1 TO GRADE 6 1996 2002 GRADUATED 2000 NONE
(STES)
SAGUDAY NATIONAL HIGH SCHOOL FIRST YEAR HIGH SCHOOL TO
SECONDARY /
VOCATIONAL 2002 2006 GRADUATED 2006 TOP 10
(SNHS) FOURTH YEAR HIGH SCHOOL

NONE NONE NONE NONE NONE NONE NONE

TRADE
BACHELOR OF SCIENCE IN
COURSE
COLLEGE SAIN'T MARY'S UNIVERSITY 2006 2010 GRADUATED 2010 NONE
MANAGEMENT ACCOUNTING
SPECIAL COURSE (EARNING UNITS IN
COLLEGE QUIRINO STATE UNIVERSITY 2018 2019 18 UNITS 2019 NONE
EDUCATION)

GRADUATE STUDIES NONE NONE NONE NONE NONE NONE NONE

(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
2/13/2020-
LICENSURE EXAM FOR TEACHERS 83.4 9/29/2019 TUGUEGARAO CITY 1873214 12/15/2023

(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.
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)
ACCOUNTING OFFICE/MALLIG PLAINS
6/15/2010 11/15/2012 GENERAL BOOKKEEPER 12,000.00 N/A REGULAR N
RURAL BANK INC.(MPRBI)
ACCOUNTING OFFICE/DEPED-DIFFUN
1/25/2021 PRESENT ADAS II 19,744.00 "08-01" PERMANENT Y
NATIONAL HIGH SCHOOL

(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

NONE NONE NONE NONE NONE

(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
JAA RESOURCE CENTER, QUIRINO STATE
TRAINING-WORKSHOP ON DEVELOPING LEARNER'S LIFE COMPETENCIES 4/27/2019 4/29/2019 8 TECHNICAL
UNIVERSITY
MALLIG PLAINS COLLEGES TRAINING CENTER 02,
UPDATES ON ANTI-MONEY LAUNDERING RULES AND REGULATIONS 4/14/2011 4/14/2011 6 TECHNICAL
CASILI, MALLIG, ISABELA
TONUS GYMNASIUM, SAINT MARY'S UNIVERSITY.
CRITICAL THINKING AND CONVERSATION FLUENCY 12/20/2008 12/20/2008 6 TECHNICAL
BAYOMBONG, NUEVA VIZCAYA

(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)
PROFICIENT IN MS WORD, EXCEL, AND
NONE NONE
POWERPOINT
CAN COMMUNICATE WELL IN ENGLISH NONE NONE

BOOKKEEPING NONE NONE

(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
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? RESIGNATION FROM 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
RUBEN C. RAFANAN CAUAYAN CITY, ISABELA 09350512873 4.5 cm. X 3.5 cm
(passport size)

MAGDALENA P. LAYUGAN RIZAL, DIFFUN, QUIRINO 09279580803

Computer generated
or photocopied picture
ROGELIO C. SUBIA, JR. DIFFUN, QUIRINO 9363700378 is not acceptable

LALAINE BORJA CABARROGUIS, QUIRINO 09255579067

LIEZLE BAUTISTA DIFFUN, QUIRINO 09174608879

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/License/Passport No.: 1873214

Signature (Sign inside the box)

Date/Place of Issuance: 2/13/2020-ROBINSONS SANTIAGO

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