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 ag
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

I. PERSONAL INFORMATION
2. SURNAME SABINIANO
NAME EXTENSION (JR., SR
FIRST NAME SHAIRA

MIDDLE NAME DALISAY

3. DATE OF BIRTH
(mm/dd/yyyy) 1/16/1996 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH DAGUPAN CITY, PANGASINAN If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male ✘ Female

✘ Single Married 17. RESIDENTIAL ADDRESS #560 LUNET

6 CIVIL STATUS
House/Block/Lot No. S
Widowed Separated
LIBSO
Other/s:
Subdivision/Village Ba
LINGAYEN PANG
7. HEIGHT (m) 1.4732 m
City/Municipality Pr
8. WEIGHT (kg) 41 kg. ZIP CODE

18. PERMANENT ADDRESS #560 LUNET

9. BLOOD TYPE O+
House/Block/Lot No. S
LIBSO
10. GSIS ID NO. 2005392389
Subdivision/Village Ba
LINGAYEN
11. PAG-IBIG ID NO.
City/Municipality Pr

12. PHILHEALTH NO. 05-251400697-0 ZIP CODE 2401

13. SSS NO. 19. TELEPHONE NO. 636-0919

14. TIN NO. 724-199-682-000 20. MOBILE NO. 0927-387-9377 / 0917-713-1241

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) sabinianoshairadalisay@yahoo.

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 N/A

MIDDLE NAME

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME SABINIANO

NAME EXTENSION (JR., SR)
FIRST NAME DIONIE

MIDDLE NAME DALISAY

25. MOTHER'S MAIDEN NAME

SURNAME DALISAY

FIRST NAME MA. LUISA

MIDDLE NAME CAÑERO (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 LIBSONG ELEMENTARY SCHOOL 6/6/2002 3/28/2008

3/28/2001
SECONDARY /
VOCATIONAL PANGASINAN NATIONAL HIGH SCHOOL 6/9/2008
2

TESDA-PANGASINAN TECHNOLOGICAL
INSTITUTE BINMALEY
FOOD AND BEVERAGE SERVICES NC II 6/5/2017 9/8/2017

TRADE
COURSE
COLLEGE PANGASINAN STATE UNIVERSITY-LINGAYEN BACHELOR OF SECONDARY EDUCATION 6/12/2012 6/22/2016

LYCEUM-NORTHWESTERN UNIVERSITY,
GRADUATE STUDIES
DAGUPAN
MASTER IN EDUCATION-FILIPINO 5/6/2017 PRESENT 18 UNITS
(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM
L DATA SHEET
erience Sheet shall cause the filing of administrative/criminal case/s against the person

EFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Dual Citizenship
by naturalization
Pls. indicate country:

LUNETA STREET
Street
LIBSONG EAST
Barangay
PANGASINAN
Province

LUNETA STREET
Street
LIBSONG EAST
Barangay
PANGASINAN
Province

636-0919

0927-387-9377 / 0917-713-1241

sabinianoshairadalisay@yahoo.com

DATE OF BIRTH (mm/dd/yyyy)

N/A
 (Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2008

2012

2017

2016

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

LICENSURE EXAMINATION FOR TEACHERS

79.2 9/25/2016 BAGUIO CITY 1505107
(LET)

(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

DepEd San Carlos City -SPEAKER EUGENIO Regular

9/18/2017 11/16/2017 TEACHER-1 SUBSTITUTE PEREZ NATIONAL AGRICULTURAL SCHOOL
₱19,620.00 11-1
Substitute
 (Continue on separate sheet if necessary)

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

Date of
Validity

1/16/2019

arate sheet if necessary)

GOV'T
SERVICE

(Y/
N)
Yes
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

(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

ICT Training and Google Productivity 9/27/2017 9/28/2018 16 hours San Ca

TESDA-P
Food And Beverage Services NC II Trainings 6/5/2017 9/8/2017 360 hours

PC Net Enterprise Workshop 5/8/2017 5/23/2017 120 hours

Employability & Enhancement Seminar: Education to Employment: Building Bridges

5/4/2016 5/4/2016 8 hours PSU
towards ASEAN Excellence
Enhancement Seminar in Innovative and Interactive Teaching Strategies: Preparing PSU Lingayen
4/30/2016 4/30/2016 8 hours
Teachers for Teaching Excellence Assoc
TERTULYA SA PANITIKANG PANGASINAN kaugnay ng pagdiriwang ng Buwan ng Pangasina
4/29/2016 4/29/2016 8 hours
Panitikang Filipino Bayambang
Student Teacher's Congress Teaching Excellence: Preparing PSU Practice Teachers
4/13/2016 4/13/2016 8 hours Pa
for Global Engagement
Supreme
Unleash The Leadership Ignited Within 12/19/2015 12/20/2015 16 hours

Supreme
LIDERATO: Youth Empowerment Seminar Leadership Through the Changing Times 7/16/2015 7/16/2015 8 hours

1st Cast Chronicle Seminar Workshop on Campus Journalism CC: Training Future Pangasinan
7/21/2014 7/21/2014 8 hours
Journalists for Positive Social Change CAST
Orientation Seminar on the OMB Powers and Functions and the Junior Graft watch
10/6/2011 107/2011 16 hours O
Unit Program

VIII. OTHER INFORMATION
31. SPECIAL SKILLS and HOBBIES 32.
Have special skills in acting and dancing
Strong technical proficiency in Microsoft
Office (Excel, Word, PowerPoint, etc)
Efficient and organized. Team player with
good coordinating skills.
SIGNATURE
(Continue on separate sheet if necessary)
MEMBERS
NON-ACADEMIC DISTINCTIONS / RECOGNITION
33.
(Write in full)
Kas
Judge in Cookery during 2017 Nutrition Month Celebration
Filip
3rd Place(Sports Writing , Filipino) -1st CAST Chronicle Workshop on Campus
Journalism(July 21, 2014)
Buwan ng Wika 2013: Sabayang Pagbigkas
(Continue on separate sheet if necessary)
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)

San Carlos City Schools Division Office

TESDA-Pangasinan Technological Institute

Binmaley

PC Net Enterprise

PSU-Lingayen Campus & PESO

PSU Lingayen Campus in Cooperation with PhilippineFor

Association Teacher Education (PAFTE)
Pangasinan State University- Sentro ng Wika at
Bayambang Campus & Komisyon sa Wikang Filipino

Pangasinan State University

Supreme Student Council - PSU Lingayen

Campus
Supreme Student Council - PSU Lingayen
Campus
Pangasinan State University-Lingayen campus &
CAST Chronicle Student Publication

Office of the Ombudsman

eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)
Kaspisanan ng Mag-aaral sa
Filipino (KAMFIL) 2012-2016

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 ✘ 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
PANGASINAN NATIONAL HIGH the last 6 months
MRS. YOLANDA U. DELA CRUZ, Filipino Department SCHOOL
3.5 cm. X 4.5 cm
(passport size)
PANGASINAN STATE UNIVERSITY-
DR. PERLA C. URBANO. Professor LINGAYEN
With full and handwritten
name tag and signature over
printed name
TESDA-PANGASINAN TECHNOLOGICAL
MRS. IRENE C. GARCIA INSTITUTE BINMALEY
0918-411-0301
Computer generated
42. or photocopied picture
I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and 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.: 1505107

Signature (Sign inside the box)

Date/Place of Issuance: Baguio 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