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 ABARICO
NAME EXTENSION (JR., SR)
FIRST NAME ROSZALD BETELGUESE

MIDDLE NAME TUMULAK

3. DATE OF BIRTH
(mm/dd/yyyy) 04/29/1984 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH CEBU CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS Single Married 17. RESIDENTIAL ADDRESS MUSTANG

Widowed ✘ Separated House/Block/Lot No. Street
PUSOK
Other/s:
Subdivision/Village Barangay
LAPU-LAPU CITY CEBU
7. HEIGHT (m) 1.7
City/Municipality Province
8. WEIGHT (kg) 60 ZIP CODE

18. PERMANENT ADDRESS MUSTANG

9. BLOOD TYPE
House/Block/Lot No. Street
PUSOK
10. GSIS ID NO. 02004170921
Subdivision/Village Barangay
LAPU-LAPU CITY CEBU
11. PAG-IBIG ID NO. 121070009153
City/Municipality Province

12. PHILHEALTH NO. 12-050968166-5 ZIP CODE

13. SSS NO. 19. TELEPHONE NO. 495-8749

14. TIN NO. 292-595-050-000 20. MOBILE NO.

15. AGENCY EMPLOYEE NO. 4793689 21. E-MAIL ADDRESS (if any) Roszaldbetelguese.abarico@deped.gov.ph
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME ABARICO 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME JOAN ZS ADRIEN EMERY B. ABARICO 11/20/2008

MIDDLE NAME BEREZO E.L. ZOAN B. ABARICO 11/20/2011

OCCUPATION N/A ZACCRA DHUN B. ABARICO 5/1/2016

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME ABARICO

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

MIDDLE NAME JARABE

25. MOTHER'S MAIDEN NAME TUMULAK

SURNAME ABARICO

FIRST NAME ROSALIE

MIDDLE NAME PERFECIO (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
 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

ELEMENTARY SAINT ALPHONSUS CATHOLIC SCHOOL PRIMARY SCHOOL 1991 1996 1996

SECONDARY /
VOCATIONAL SAINT ALPHONSUS CATHOLIC SCHOOL HIGH SCHOOL 1996 2001 2001

TRADE
COURSE
COLLEGE UNIVERSITY OF CEBU-LAPULAPU & MANDAUE BACHELOR OF ELEMENTARY EDUCATION 2006 2010 2010

MASTER OF EDUCATION IN
GRADUATE STUDIES CEBU TECHNOLOGICAL UNIVERSITY
ADMINISTRATION AND SUPERVISION
2011 2013 30 UNITS
(Continue on separate sheet if necessary)

SIGNATURE DATE AUGUST 15, 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 ap
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

UNIVERSITY OF CEBU-LAPULAPU &

LICENSURE EXAMINATION FOR TEACHERS 82.2 09/26/2010 1084041
MANDAUE

(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 not (Write in SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To

08/22/2011 1/6/2014 Teacher I Lapu-Lapu City Government 15649.00 11-0 Reg. P.

Department of Education- Division of
2/6/2014 present Teacher I 19286.00 11-2 Reg.P.
LapuLapu City
 (Continue on separate sheet if necessary)

SIGNATURE DATE AUGUST 15, 2017

CS FORM 212 (Revised 20

 LICENSE (if applicable)

Date of
Validity

arate sheet if necessary)

GOV'T
SERVICE

(Y/
N)
Y

Y
arate 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

N/A

(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
 (Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

PLAYING MUSICAL INSTRUMENTS N/A

PLAYING BASKETBALL

(Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

eparate sheet if necessary)

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

CONDUCTED/ SPONSORED BY
(Write in full)
eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

N/A

eparate sheet if necessary)

AUGUST 15, 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 If YES, give details:
✘ NO

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? YES If 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 within
MACTAN AIR BASE ELEMENTARY the last 6 months
IMELDA G. NAVEO SCHOOL
268-4069 3.5 cm. X 4.5 cm
(passport size)

CZARINA RITZCO J. SAGARINO BANKAL ELEMENTARY SCHOOL 495-2979 With full and handwritten
name tag and signature over
printed name
MARILOU O. VALLECERA BUAYA ELEMENTARY SCHOOL 495-8922
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 13091152
Government Issued ID: 006017709938

ID/License/Passport No.: g11-08-001366

Signature (Sign inside the box)
AUGUST 15, 2017
Date/Place of Issuance: 01/19/17// LAPULAPU 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 o

If YES, give details (country):
, affiant exhibiting his/her validly issued government ID as indicated above.

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