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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 cas
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.

I. PERSONAL INFORMATION
2. SURNAME BULAGNIR

FIRST NAME GENWARD

MIDDLE NAME LAMUSAO


3. DATE OF BIRTH
(mm/dd/yyyy) 10/5/1993 16. CITIZENSHIP Filipino Dual Cit

4. PLACE OF BIRTH BRGY. SAN FRANCISCO CATUBIG If holder of dual citizenship,

please indicate the details.


5. SEX Male Female

Single Married 17. RESIDENTIAL ADDRESS N/A


6 CIVIL STATUS
Widowed Separated House/Block/Lot No.
N/A
Other/s:
Subdivision/Village
CATBALOGAN CITY
7. HEIGHT (m) 1.69
City/Municipality
8. WEIGHT (kg) 54 ZIP CODE 6418
18. PERMANENT ADDRESS N/A
9. BLOOD TYPE A
House/Block/Lot No.
N/A
10. GSIS ID NO. NONE
Subdivision/Village
CATUBIG
11. PAG-IBIG ID NO. 121126679624
City/Municipality

12. PHILHEALTH NO. 03-025655754-8 ZIP CODE

13. SSS NO. 34-4727790-1 19. TELEPHONE NO. NONE

14. TIN NO. 318-914-333 20. MOBILE NO. 09056533657

15. AGENCY EMPLOYEE NO. 6291558 21. E-MAIL ADDRESS (if any) genward.bulagnir@g
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) N/A
FIRST NAME N/A

MIDDLE NAME N/A N/A

OCCUPATION N/A N/A

EMPLOYER/BUSINESS NAME N/A N/A

BUSINESS ADDRESS N/A N/A

TELEPHONE NO. N/A N/A

24. FATHER'S SURNAME BULAGNIR N/A


SENIOR N/A
FIRST NAME WILLIAM

MIDDLE NAME GALIT N/A

25. MOTHER'S MAIDEN NAME N/A

SURNAME LAMUSAO N/A

FIRST NAME GEMMA N/A

MIDDLE NAME CUNTAPAY (Continue on separate sheet

III. EDUCATIONAL BACKGROUND

26. NAME OF SCHOOL PERIOD OF ATTENDANCE


BASIC EDUCATION/DEGREE/COURSE
LEVEL (Write in
(Write in full)
full)
From To

ELEMENTARY CATUBIG CENTRAL ELEMENTARY SCHOOL PRIMARY EDUCATION 6/4/2004 3/31/2006

SECONDARY CATUBIG VALLEY NATIONAL HIGH SCHOOL HIGH SCHOOL 6/5/2006 4/5/2010
VOCATIONAL /

FAIR GEMS ACADEMY COMPUTER HARDWARE SERVICING 8/10/2015 10/16/2015

TRADE
COURSE UNIVERSITY OF EASTERN PHILIPPINES, PEDRO
COLLEGE
REBADULLA MEMORIAL CAMPUS CATUBIG
BACHELOR OF SECONDARY EDUCATION 6/7/2010 3/31/2014

GRADUATE STUDIES N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE
AL DATA SHEET
k Experience Sheet shall cause the filing of administrative/criminal case/s against the person

DS) BEFORE ACCOMPLISHING THE PDS FORM.


(Do not fill up. For CSC use only)

NONE

Filipino Dual Citizenship

by birth by naturalization

Pls. indicate country:

N/A
Street
RAMA
Barangay
SAMAR
Province

6418
N/A
Street
CANUCTAN
Barangay
NORHTERN SAMAR
Province

6418

NONE

09056533657

genward.bulagnir@gmail.com

23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A 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)

HIGHEST LEVEL/ SCHOLARSHIP/


YEAR
UNITS ACADEMIC
GRADUATED
EARNED HONORS
(if not graduated) RECEIVED

GRADUATE 2006 NONE

GRADUATE 2010 NONE


6 UNITS 2015 NONE

GRADUATE 2014 NONE

N/A N/A NONE

ue on separate sheet if necessary)

April 28, 2017

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 appl
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

PROFESSIONAL BOARD EXAMINATION FOR


75.0 8/17/2014 MANILA 1324105
TEACHERS

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

CURRENT ANTONIO G. TUASON NATIONAL HIGH REGULAR-


6/3/2016 TEACHER-I 19000.00 11-1
DATE SCHOOL CATBALOGAN CITY, SAMAR PERMANENT
BRGY. LENOY AHAN CATUBIG, NORTHERN
2/19/2016 3/31/2016 SUBSTITUTE TEACHER 18549.00 N/A CONTRACTUAL
SAMAR
11/25/2014 9/21/2015 RECEIVING AND DISPATCHING UNIT SUPER VALUE INCORPORATION 12000.00 N/A CONTRACTUAL

SEASONAL
11/25/2014 11/14/2015 RECEIVING CLERCK RIVERA MERCANTILE SYSTEM INC. 12.000.00 N/A CONTRACUAL
(Continue on separate sheet if necessary)

SIGNATURE DATE 4/28/2017

CS FORM 212 (Revised 201


LICENSE (if applicable)

Date of
Validity

10/5/2017

eparate sheet if necessary)

GOV'T
SERVICE

(Y/ N)

YES

YES

NO

NO
eparate sheet if necessary)

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
From To

NONE NONE NONE 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
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/
Technical/etc)
From To

COMPUTER HARDWARE SERVICING NC II 5/1015 10/16/2015 392.0 TECHNICAL-VOCAFAIR GEMS A

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


MEMBER
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

ICT NONE
VOLLEY BALL NONE

BASKET BALL NONE

CHESS NONE

WUSHU NONE

(Continue on separate sheet if necessary)

SIGNATURE DATE
E / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

NONE

parate sheet if necessary)


S ATTENDED
5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

FAIR GEMS ACADEMY

parate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in
full)

NONE
NONE

NONE

NONE

NONE

parate sheet if necessary)

4/28/2017
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:


________________________________

a. Have you ever been found guilty of any administrative offense? YES NO
35.

If YES, give details:


________________________________
________________________________
YES NO
b. Have you been criminally charged before any court?
If YES, give details:
________________________________
Date Filed:
________________________________
Status of Case/s:
YES NO
36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation
by any court or tribunal?
If YES, give details:
________________________________
YES NO
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation,
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? ________________________________
YES NO
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? YES NO
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last
election to promote/actively campaign for a national or local candidate? YESIf YES, give details:
NO

39. Have you acquired the status of an immigrant or permanent resident of another country?
If YES, give details (country):

40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA YES NO
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?
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
the last 6 mo
MARVIN ACEDERA CATUBIG, NORTHERN SAMAR 9168522268 3.5 cm. X 4.5
(passport si

PEPITO ADARAYAN CATUBIG, NORTHERN SAMAR 9262159221 With full and han
name tag and sign
printed nam

Computer gene
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied p
is not accept
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.: 1324105 4/28/2017 Signature (Sign inside the box)


4/28/2017
Date/Place of Issuance: 11/17/2014 MANILA
Date Accomplished Right Thumbm

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated

Person Administering Oath

CS FORM 212 (Rev


If YES, give details:
________________________________

If YES, give details:


________________________________
________________________________

If YES, give details:


________________________________
________________________________

If YES, give details:


________________________________
________________________________

If YES, give details:


________________________________
________________________________

If YES, give details (country):

ID picture taken within


the last 6 months
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten


name tag and signature over
printed name

Computer generated
or photocopied picture
is not acceptable

PHOTO

Right Thumbmark

, affiant exhibiting his/her validly issued government ID as indicated above.

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