CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

i

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

I. PERSONAL INFORMATION
2. SURNAME MACACUNA
NAME EXTENSION (JR., SR
FIRST NAME ABDULAZIS

MIDDLE NAME TAHER

3. DATE OF BIRTH
(mm/dd/yyyy) 5/9/1995 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by birth b
4. PLACE OF BIRTH BALO-I, LANAO DEL NORTE If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX ✘ Male Female

Single Married 17. RESIDENTIAL ADDRESS 068 J.R. BORJA

6 CIVIL STATUS ✘
House/Block/Lot No. S
Widowed Separated
B
Other/s:
Subdivision/Village Ba
CAGAYAN DE ORO MISAMIS
7. HEIGHT (m)
City/Municipality Pr
8. WEIGHT (kg) ZIP CODE 9000

18. PERMANENT ADDRESS

9. BLOOD TYPE O
House/Block/Lot No. S
BALIKBAYAN WEST P
10. GSIS ID NO. N/A
Subdivision/Village Ba
Balo-i
11. PAG-IBIG ID NO. N/A
City/Municipality

12. PHILHEALTH NO. 15-025481319-4 ZIP CODE 9200

13. SSS NO. N/A 19. TELEPHONE NO. N/A

14. TIN NO. N/A 20. MOBILE NO. 09273912465

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) azispatara11@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME PATARA

NAME EXTENSION (JR., SR)
FIRST NAME MACACUNA

MIDDLE NAME MAKIL

25. MOTHER'S MAIDEN NAME BEDARIA UMPAR TAHIR

SURNAME TAHIR

FIRST NAME BEDARIA

MIDDLE NAME UMPAR (Continue on separate sheet if necessary

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL HIGHEST LEVEL/
26. BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE UNITS
LEVEL (Write in EARNED
(Write in full)
full) (if not graduated)
From To

ELEMENTARY MARIA CRISTINA CENTRAL SCHOOL PRIMARY EDUCATION 6/5/2003 3/30/2009

SECONDARY TOMAS CABILI NATIONAL HIGHSCHOOL SECONDARY EDUCATION 6/3/2009 3/29/2013

VOCATIONAL /

N/A N/A

TRADE
COURSE BACHELOR OF SCIENCE MAJOR IN
COLLEGE PACASUM COLLEGE
MANAGEMENT
6/6/2013 4/2/2017

GRADUATE STUDIES N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM
L DATA SHEET

EFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Dual Citizenship

by naturalization
Pls. indicate country:

J.R. BORJA BURGOS ST.

Street
Brgy. 7
Barangay
MISAMIS ORIENTAL
Province
9000

Street
WEST POBLACION
Barangay
Lanao del Norte

9200

N/A

09273912465

azispatara11@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

VALEDICTO
2009
RIAN
Math Wizar
2013
of the year
 Dean's
2017
Lister

parate sheet if necessary)

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

Fire Officer Exam Passer July 12 2018

(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

4/1/2013 6/1/2013 Technical Support Representative Sitel Philippines

 (Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 20
 LICENSE (if applicable)

Date of
Validity

arate sheet if necessary)

GOV'T
SERVICE

(Y/
N)
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

DSWD - Marawi City 5/1/2011 8/1/2012 4hrs Volunteer

Pacasum College - Marawi City 6/9/2014 3/5/2017 6hrs Student Assistant

(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

2nd Trainer's Training Workshops for Artists for Crisis, NCAA, Ayala resort 3/1/2010

Training for English Speakers and writers, US, AID, CALI paramedical College 10/1/2010

Disaster Management Emergency Risk Reduction and Control, MSU main 10/5/2013

Development Communications, Marawi City 1/4/2013 1/6/2013

Empowering people through Creative and unique livelihood endeavors 9/25/2013

One Day and Team Building, Libertad 9/8/2014

 (Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

Microsoft office

Ubuntu Office Applications

Adobe Photoshop

Adobe Premiere

Windows Movie Maker

Java Script & Dreamweaver

(Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

Volunteer

Student Assistant

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)

eparate 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 ✘

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? ________________________________
________________________________
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
Princess Dayana M. Pacasum Jr. Borja Ext., Cagayan de Oro City 9273912464 3.5 cm. X 4.5 cm
(passport size)

Princess Johairah Diamond P. Pangarungan Marawi City 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:

ID/License/Passport No.:
Signature (Sign inside the box)

Date/Place of Issuance:
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