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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 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 ROWANO

FIRST NAME ROMEO

MIDDLE NAME PAHAMUTANG


3. DATE OF BIRTH
(mm/dd/yyyy) 1/1/1991 16. CITIZENSHIP ✘ Filipino Dual Citizens

4. PLACE OF BIRTH IGUIG, CAGAYAN If holder of dual citizenship,

please indicate the details.


5. SEX ✘ Male Female

✘ Single Married 17. RESIDENTIAL ADDRESS


6 CIVIL STATUS
Widowed Separated House/Block/Lot No.

Other/s:
Subdivision/Village
IGUIG
7. HEIGHT (m) 1.55
City/Municipality
8. WEIGHT (kg) 41 ZIP CODE 3504

18. PERMANENT ADDRESS


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

10. GSIS ID NO. NONE


Subdivision/Village
IGUIG
11. PAG-IBIG ID NO. 1211-7958-6378
City/Municipality

12. PHILHEALTH NO. 06-050209374-9 ZIP CODE 3504

13. SSS NO. 0111-7085014-7 19. TELEPHONE NO. NONE

14. TIN NO. 490-036-279-000 20. MOBILE NO. 09651445714

15. AGENCY EMPLOYEE NO. NONE 21. E-MAIL ADDRESS (if any) NONE

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

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME ROWANO

FIRST NAME MARIO

MIDDLE NAME COLEMNARES

25. MOTHER'S MAIDEN NAME

SURNAME PAHAMUTANG

FIRST NAME HERMINIA

MIDDLE NAME QUESEO (Continue on separate sheet if

III. EDUCATIONAL BACKGROUND

26. NAME OF SCHOOL PERIOD OF ATTENDANCE


BASIC EDUCATION/DEGREE/COURSE
LEVEL (Write in
(Write in full)
full)
26. NAME OF SCHOOL PERIOD OF ATTENDANCE
BASIC EDUCATION/DEGREE/COURSE
LEVEL (Write in
(Write in full)
full)
From To

ELEMENTARY IGUIG CENTRAL SCHOOL ELEMENTARY EDUCATION 1999 2005

SECONDARY
VOCATIONAL / VICENTE D. TRINIDAD HIGH SCHOOL SECONDARY EDUCATION 2005 2009

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

TRADE
COURSE
COLLEGE CAGAYAN STATE UNIVERSITY BACHELOR OF SECONDARY EDUCATION 2011 2015

GRADUATE STUDIES NONE NONE NONE NONE

(Continue on separate sheet if necessary)

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

(PDS) BEFORE ACCOMPLISHING THE PDS FORM.


(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

✘ Filipino Dual Citizenship


by birth by naturalization

Pls. indicate country:

Street
SAN LORENZO
Barangay
Cagayan
Province
3504

Street
SAN LORENZO
Barangay
Cagayan
Province

NONE

09651445714

NONE

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

N/A N/A

(Continue on separate sheet if necessary)

HIGHEST LEVEL/
SCHOLARSHIP/
UNITS YEAR
ACADEMIC HONORS
EARNED GRADUATED
RECEIVED
(if not graduated)
HIGHEST LEVEL/
SCHOLARSHIP/
UNITS YEAR
ACADEMIC HONORS
EARNED GRADUATED
RECEIVED
(if not graduated)

5TH
2005
HONOR

2009 N/A

N/A N/A

2015 N/A

NONE NONE

nue on separate sheet if necessary)

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


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

LET 75.00% 09/27/2015 TUGUEGARAO CITY, CAGAYAN 1398601 01/01/2021

(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)
01/03/2018 04/06/2018 SUBSTITUTE TEACHER GAMMAD NATIONAL HIGH SCHOOL SUBSTITUTE YES

09/25/2017 12/08/2017 SUBSTITUTE TEACHER GAMMAD NATIONAL HIGH SCHOOL SUBSTITUTE YES

06/05/2016 03/30/2017 TEACHER LA SALETTE OF QUEZON CONTRACTUAL NO

(Continue on separate sheet if necessary)

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


INCLUSIVE DATES
29. NAME & ADDRESS OF ORGANIZATION
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION
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
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To

IN SERVICE TRAINING 10/23/2017 10/27/2017

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


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

Computer Literate NONE

(Continue on separate sheet if necessary)

SIGNATURE DATE
POSITION / NATURE OF WORK

separate sheet if necessary)

PROGRAMS ATTENDED
ast five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

MRS. CORAZON A. CAMAYANG

separate sheet if necessary)


MEMBERSHIP IN ASSOCIATION/ORGANIZATION

(Write in full)

NONE

separate sheet if necessary)

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 NO
YES ✘
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 withi
Vicente D. Trinidad High School, Iguig, the last 6 months
LEO R. BANATAO Cagayan
0917-581-6988 3.5 cm. X 4.5 cm
(passport size)
Gammad National High School, Iguig,
CORAZON A. CAMAYANG Cagayan
0917-519-8475 With full and handwrit
name tag and signature
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 pictur
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/License/Passport No.: 1398601 Signature (Sign inside the box)

Date/Place of Issuance: 12/11/2015 - Tuguegarao City


Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated ab
Person Administering Oath
If YES, give details:
________________________________

If YES, give details:


________________________________
________________________________

If YES, give details:


________________________________
________________________________

If YES, give details:


________________________________
________________________________

If YES, give details:


________________________________
________________________________
✘ NO

✘ NO

✘ NO
If YES, give details (country):

✘ NO

✘ NO

✘ NO

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.