CS Form No.

212
Revised 2017
PERSONAL DATA SHEET
WARNING: Any misinterpretation 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 SUMAGDON

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

MIDDLE NAME NAVALES

3. DATE OF BIRTH
(mm/dd/yyyy) 02/10/1990 16. CITIZENSHIP
Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH METRO, MANILA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female

6 CIVIL STATUS Single Married17. RESIDENTIAL ADDRESS

Widowed Separat House/Block/Lot No. Street

Other/s: ed PALALE
Subdivision/Village Barangay

7. HEIGHT (m) 1.57 STA. MARGARITA SAMAR

City/Municipality Province
8. WEIGHT (kg) 48 ZIP CODE 6709

18. PERMANENT ADDRESS

9. BLOOD TYPE O
House/Block/Lot No. Street

10. GSIS ID NO. 2005091741 PALALE

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121172396855 STA. MARGARITA SAMAR

City/Municipality Province

12. PHILHEALTH NO. 130501405605 ZIP CODE 6709

13. SSS NO. 06-3223116-6 19. TELEPHONE NO. NONE

14. TIN NO. 490-918-528-000 20. MOBILE NO. 09362132505

15. AGENCY EMPLOYEE NO. 6293527 21. E-MAIL ADDRESS (if any) antholinnavales@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

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME SUMAGDON

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

MIDDLE NAME

25. MOTHER'S MAIDEN NAME

SURNAME NAVALES

FIRST NAME EMMA

MIDDLE NAME SABARIA (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 GRADUATED
(Write in full) EARNED HONORS
full) (if not graduated) RECEIVED
From To

ELEMENTARY SOLSOGON ELEMENTARY SCHOOL PRIMARY EDUCATION 1997 2005 N/A 2005

CALBAYOG CITY NATIONAL HIGH

SECONDARY /
VOCATIONAL HIGH SCHOOL 2005 2010 N/A 2010
SCHOOL

NONE
TRADE
BACHELOR OF SCIENCE IN INDUSTRIAL
COURSE
COLLEGE NORTHWEST SAMAR STATE UNIVERSITY TECHNOLOGY MAJOR IN ELECTRONICS
2010 2014 N/A 2014

MASTER TECHNICIAN IN EDUCATION MAJOR IN

GRADUATE STUDIES SAMAR STATE UNIVERSITY ELECTRONICS TECHNOLOGY
2014 2016 36 UNITS N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE 02/03/2017 CS FORM 212 (Revised 2017), Page 1 of 4

CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable)
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

NONE

(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.
SALARY/ JOB/
28. INCLUSIVE DATES PAY GRADE (if
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY applicable)&
(Write in full/Do not (Write in SALARY STEP (Format
abbreviate) full/Do not abbreviate) "00-0")/
From To INCREMENT

TEACHER II (SENIOR HIGH SCHOOL - DEPARTMENT OF EDUCATION/STO. NIO NATIONAL

06/15/2016 PRESENT
TECHNICAL -VOCATIONAL TRACK ) HIGH SCHOOL/ SENIOR HIGH SCHOOL
21387.00 12-1

05/04/2013 06/10/2016 CHEF DEMETRIUS' BREAD, COFFEE AND WINE 9500.00 N/A

12/10/2010 06/13/2013 BARTENDING AND FOOD ATTENDANT DEMETRIUS' BREAD, COFFEE AND WINE 6000.00 N/A
 (Continue on separate sheet if necessary)

SIGNATURE DATE 05/03/2017 CS FORM 212 (Re

CS FORM 2
 LICENSE (if applicable)

NUMBER Date of
Validity

e on separate sheet if necessary)

of duties should be indicated in the attached Work Experience sheet.

GOV'T
SERVICE
STATUS OF
APPOINTMENT

(Y/ N)

PROVISIONAL Y

PERMANENT N

PERMANENT N
e on separate sheet if necessary)

CS FORM 212 (Revised 2017), Page 2 of 4

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

(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

JOB ORIENTATION FOR NEWLY HIRED SENIOR HIGH SCHOOL TEACHERS 03/01/2017 03/03/2017 24 TECHNICAL DEPARTMENT OF EDUCATION

TECHNICAL EDUCATION AND SKILL DEVELOPMENT

NATIONAL CERTIFICATE II IN COOKERY ( AMMENDED) 05/10/2016 06/08/2016 436 TECHNICAL
AUTHORITY
TECHNICAL EDUCATION AND SKILL DEVELOPMENT
NATIONAL CERTIFICATE II IN FOOD AND BEVERAGE SERVICES ( AMMENDED) 05/10/2016 06/07/2016 336 TECHNICAL
AUTHORITY

MASS TRAINING OF TEACHER FOR SENIOR HIGH SCHOOL GRADE 11 ( TVL TRACK) 06/20/2016 06/28/2016 72 TECHNICAL DEPARTMENT OF EDUCATION

SENIOR HIGH SCHOOL GRADE 11 MASS TRAINING OF TEACHER (COMMON

07/02/2016 07/05/2016 32 TECHNICAL DEPARTMENT OF EDUCATION
TOPIC )
TECHNICAL EDUCATION AND SKILL
NATIONAL CERTIFICATE II IN ELECTRICAL INSTALLATION AND MAINTENACE 12/01/2015 12/20/2015 80 TECHNICAL
DEVELOPMENT AUTHORITY
TECHNICAL EDUCATION AND SKILL
TRAINERS METHODOLOGY CERTIFICATE I 10/02/2015 11/21/2015 123 TECHNICAL
DEVELOPMENT AUTHORITY
TECHNICAL EDUCATION AND SKILL
NATIONAL CERTIFICATE II IN BREAD AND PASTRY PRODUCTION 09/10/2013 10/20/2013 141 TECHNICAL
DEVELOPMENT AUTHORITY
TECHNICAL EDUCATION AND SKILL
NATIONAL CERTIFICATE II IN BARTENDING 08/10/2013 09/05/2013 286 TECHNICAL
DEVELOPMENT AUTHORITY
TECHNICAL EDUCATION AND SKILL
NATIONAL CERTIFICATE II IN HOUSEKEEPING 08/10/2013 09/10/2013 436 TECHNICAL
DEVELOPMENT AUTHORITY
TECHNICAL EDUCATION AND SKILL
NATIONAL CERTIFICATE II IN COMMERCIAL COOKING 11/20/2012 01/015/2013 436 TECHNICAL
DEVELOPMENT AUTHORITY
NATIONAL CERTIFICATE II IN FOOD AND TECHNICAL EDUCATION AND SKILL
11/20/2012 01/15/2013 336 TECHNICAL
BEVERAGE DEVELOPMENT AUTHORITY
NATIONAL CERTIFICATE II IN SHEILDED TECHNICAL EDUCATION AND SKILL
06/10/2012 08/25/2012 268 TECHNICAL
METAL ARC WELDING DEVELOPMENT AUTHORITY

(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)
CERTIFICATE OF RECOGNITION AS RESOURCE SPEAKER IN CAREER GUIDANCE ORIENTATION NATIONAL TVET TRAINER CERTICATE LEVEL
COMPUTER LITERATE PROGRAM IN STO.NIO NATIONAL HIGH SCHOOL I IN SHIELDED METAL ARC WELDING
NATIONAL TVET TRAINER CERTICATE LEVEL
VOLLEYBALL CERTIFICATE OF RECOGNITION AS COACH IN 2016 DIVISION FESTIVAL OF TALENT-TECHNOLYMPIC
I IN BREAD AND PASTRY PRODUCTION
CERTIFICATE OF APPRECIATION AS TRAINER TECHNOLOGY AND LIVELIHOOD EDUCATION SCHOOL
COOKING SKILL COMPETITION AT STO.NIO NATIONAL HIGH SCHOOL

(Continue on separate sheet if necessary)

SIGNATURE DATE 05/03/2017

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
MR. DEMETRIO C. DIMARANAN BRGY.BALUD CALBAYOG CITY 9173160725 3.5 cm. X 4.5 cm
(passport size)

MS.DEBORAH A. DIMARANAN BRGY. BALUD CALBAYOG CITY 9772079775 With full and handwritten
name tag and signature over
printed name

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: BIR TIN

ID/License/Passport No.: 490-918-528-200

Signature (Sign inside the box)
05/03/2017
Date/Place of Issuance: 10/06/2016/CATBALOGAN 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