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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 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 FLORES
NAME EXTENSION (JR., SR)
FIRST NAME HAZEL
MIDDLE NAME DELA CERNA
3. DATE OF BIRTH
(mm/dd/yyyy) SEPTEMBER 10, 1975 16. CITIZENSHIP
✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH DAVAO CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female Peru

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS 35 QUARTZ


Widowed Separated House/Block/Lot No. Street
CRYSTAL MEADOWS SASA
Other/s:
Subdivision/Village Barangay
DAVAO CITY DAVAO DEL SUR
7. HEIGHT (m) 5'9(175.26 CENTEMETER)(69 INCH)
City/Municipality Province
8. WEIGHT (kg) 181 ZIP CODE

9. BLOOD TYPE O 18. PERMANENT ADDRESS 35 STREET


House/Block/Lot No. Street
10. GSIS ID NO. 75091001349 CRYSTAL MEADOWS SASA
Subdivision/Village Barangay
11. PAG-IBIG ID NO. 1880-0029-3502 DAVAO CITY DAVAO DEL SUR
City/Municipality Province

12. PHILHEALTH NO. 16-050248784-9 ZIP CODE 8000

13. SSS NO. 09-2146772-2 19. TELEPHONE NO.

14. TIN NO. 939-268-723 20. MOBILE NO. 09153502743

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) HAZELDELACERNAFLORES@GMAIL.COM
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

NAME EXTENSION (JR., SR)


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 FLORES JUNE 14, 1949
NAME EXTENSION (JR., SR)
FIRST NAME HERNANE
MIDDLE NAME TUMNOG
25. MOTHER'S MAIDEN NAME ESCAL MAY 27, 1943
SURNAME DELA CERNA
FIRST NAME ZAIDA
MIDDLE NAME ESCAL (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 EARNED
GRADUATED
HONORS
(Write in full)
full) (if not graduated) RECEIVED
From To

ELEMENTARY OUR LADY OF FATIMA ACADEMY 1982 1998 1998


VOCATIONAL /
SECONDARY DAVAO CITY HIGH SCHOOL 1988 1992 1992
GENERAL RADIO COMMUNICATION
UNIVERSITY OF MINDANAO
OPERATOR (GRCO)
1992 1994 1994

COLLEGE TRADE HOLY CROSS OF DAVAO COLLEGE COMMERCE- MARKETING 1995 2000 2000
COURSE
COLLEGE HOLY CROSS OF DAVAO COLLEGE BSED - FILIPINO 2000 2003 2003

GRADUATE STUDIES HOLY CROSS OF DAVAO COLLEGE M.A - FILIPINO 35 UNITS


(Continue on separate sheet if necessary)

SIGNATURE DATE
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 applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity

LET 75.20 AUGUST 29, 2004 UNIVERSITY OF IMACULATE CONCEPTION 0863123 11/30/04

(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
(mm/dd/yyyy) MONTHLY GRADE (if applicable)& STATUS OF
(Write in full/Do not (Write in SALARY STEP (Format "00-0")/ APPOINTMENT
abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)
01/01/19 PPRESENT Teacher III Davao City National High School 24,510.00 Permanent Yes

09/03/18 12/31/18 Teacher III Davao City National High School 24,510.00 Step 2 Permanent Yes

01/01/18 09/02/18 Teacher III Davao City National High School 24,224.00 E.O. # 201 Permanent Yes

01/01/17 12/31/17 Teacher III Davao City National High School 23,257.00 E.O. # 201 Permanent Yes
S/A NBC#
01/01/16 12/31/116 Teacher III Davao City National High School 22,328.00 Permanent Yes
562,E.O.#201
Promoted (SG
09/03/15 12/31/15 Teacher III Davao City National High School 20,140.00 Permanent Yes
13,Step 1)
01/01/15 09/02/15 Teacher II Davao City National High School 19.940.00 Step 2 Permanent Yes

Promoted(SG
06/24/13 12/31/14 Teacher II Davao City National High School 19,940.00 Permanent Yes
12, Step 1)

10/12/12 06/23/13 Teacher I Davao City National High School 18,735.00 S/A E.O.# 76 Permanent Yes

06/01/12 10/11/12 Teacher I Davao City National High School 17,318.00 S/A E.0.#40 Permanent Yes

06/01/11 05/31/12 Teacher I Davao City National High School 15,900.00 S/A E.O.#900 Permanent Yes

06/24/10 05/31/11 Teacher I Davao City National High School 14,483.00 SG-11, Step 2 Permanent Yes

S/A
02/13/10 06/23/10 Teacher I Davao City National High School 14,198.00 E.O.3811(SG Permanent Yes
11,Step1)
07/01/08 02/12/10 Teacher I Davao City National High School 12,026.00 S/A E.O.#719 Permanent Yes

07/01/07 06/30/08 Teacher I Davao City National High School 10,933.00 S/A E.O.#611 Permanent Yes

02/13/07 06/30/07 Teacher I Davao City National High School 9,939.00 Permanent Yes

10/27/06 12/21/06 Teacher I Davao City National High School 9,939.00 Permanent Yes
(Continue on separate sheet if necessary)

SIGNATURE DATE
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 / NATURE OF WORK
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/ SPONSORED BY
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

Results-Based Performance Management System( RPMS) July 30, 2018 Aug. 1, 2018 24 hours Davao City National High School

School Based Rool Out Results-Based Performance Management System( RPMS) Aug 3, 2018 Aug 3, 2018 8 hours Davao City national High School

Panrehiyong Pagsasanay ng mga Guro s Kritikal na Nilalaman ng Kurikulum sa Filipino


Mayo 30, 2018 Hunyo 3, 2018 24 hours Region XI / kagawaran ng Edukasyon
(Baitang 7)
Capacity Building on Teachers and Guidance Counselors Collaboration in Honing
June 29, 2018 June 29, 2018 8 hours Davao City national High School
Learners

ISO9001:2015 Awareness Seminar/Workshop Feb. 7, 2018 Feb 7, 2018 8 hours Davao City national High School

Training-Workshop on the Development of Non-Print Materials April 12, 1018 April 13, 2018 16 hours DepEd

(TWG)Contextualization Writeshop in MTB-MLE at Panrehiyong pagsasany sa Filipino Dec. 27, 2016 Dec 29, 2016 24 hours Region XI / kagawaran ng Edukasyon

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


MEMBERSHIP IN ASSOCIATION/ORGANIZATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33. (Write in
(Write in full)
full)
(Continue on separate sheet if necessary)

SIGNATURE DATE
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
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
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:

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 of 4