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 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 GONGON
NAME EXTENSION (JR., SR) N/A
FIRST NAME RAFAEL

MIDDLE NAME LAJOM

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 4/28/1982 ✘ Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH SAN RAFAEL, BULACAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female
6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS 873

Widowe Separat House/Block/Lot No. Street

CAINGIN
d ed
Other/s: Subdivision/Village Barangay
SAN RAFAEL BULACAN
7. HEIGHT (m) 1.64 m
City/Municipality Province
8. WEIGHT (kg) 66 kg ZIP CODE 3008

18. PERMANENT ADDRESS 873

9. BLOOD TYPE A+
House/Block/Lot No. Street
CAINGIN
10. GSIS ID NO. 02004017150
Subdivision/Village Barangay
SAN RAFAEL BULACAN
11. PAG-IBIG ID NO. 1210-2819-7354
City/Municipality Province

12. PHILHEALTH NO. 21-000003410-4 ZIP CODE 3008

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

14. TIN NO. 239-054-409 20. MOBILE NO. 0932 2150 503

15. AGENCY EMPLOYEE NO.
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME
FIRST NAME
4274485 21. E-MAIL ADDRESS (if any) rafaelgongon2@gmail.com
GONGON 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
RODA KATE RAFUNZEL L. GONGON 4/13/2003

MIDDLE NAME LAZARO N/A N/A

OCCUPATION TEACHER N/A N/A

EMPLOYER/BUSINESS NAME DEPARTMENT OF EDUCATION PANDI NORTH N/A N/A

BUSINESS ADDRESS POBLACION,PANDI,BULACAN N/A N/A

TELEPHONE NO. N/A N/A N/A

24. FATHER'S SURNAME GONGON N/A N/A

NAME EXTENSION (JR., SR)
FIRST NAME ROGELIO N/A N/A N/A

MIDDLE NAME TADEO N/A N/A

25. MOTHER'S MAIDEN NAME LAJOM N/A N/A

SURNAME GONGON N/A N/A

FIRST NAME DOLORES N/A N/A

MIDDLE NAME BERNARDINO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY CAINGIN ELEMENTARY SCHOOL PRIMARY EDUCATION 1989 1995 N/A 1995 N/A

SECONDARY /
VOCATIONAL SAN RAFAEL NATIONAL TRADE SCHOOL HIGH SCHOOL 1995 1999 N/A 1999 N/A

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

TRADE
COURSE
COLLEGE SAINT AUGUSTINE COLLEGE BACHELOR OF ELEMENTARY EDUCATION 2000 2004 N/A 2004 N/A

MASTER OF EDUCATION MAJOR IN

GRADUATE STUDIES BULACAN AGRICULTURAL STATE COLLEGE
MANAGEMENT
2012 2014 33 UNITS N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 4/27/2017 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 applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity

LICENSURE EXAMINATION FOR TEACHERS 75.40 8/29/2009 ANGELES CITY, PAMPANGA 0860073 4/28/2019

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

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

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

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

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

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

(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 GOV'T SERVICE
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)

DEPARTMENT OF EDUCATION REGULAR

11/8/2016 PRESENT CLASSROOM TEACHER I 19496.00 11-3 YES
PANDI NORTH DISTRICT PERMANENT
DEPARTMENT OF EDUCATION REGULAR
1/1/2016 11/7/2016 CLASSROOM TEACHER I 19496.00 11-3 YES
SAN RAFAEL WEST DISTRICT PERMANENT
DEPARTMENT OF EDUCATION SAN REGULAR
1/5/2016 12/31/2015 CLASSROOM TEACHER I 18922.00 11-3 YES
RAFAEL WEST DISTRICT PERMANENT
DEPARTMENT OF EDUCATION REGULAR
6/1/2012 1/4/2015 CLASSROOM TEACHER I 18735.00 11-2 YES
SAN RAFAEL WEST DISTRICT PERMANENT
DEPARTMENT OF EDUCATION REGULAR
1/5/2012 5/31/2012 CLASSROOM TEACHER I 17318.00 11-2 YES
SAN RAFAEL DISTRICT PERMANENT
DEPARTMENT OF EDUCATION REGULAR
6/1/2011 1/4/2012 CLASSROOM TEACHER I 17099.00 11-1 YES
SAN RAFAEL DISTRICT PERMANENT
DEPARTMENT OF EDUCATION REGULAR
6/24/2010 5/31/2011 CLASSROOM TEACHER I 15649.00 11-1 YES
SAN RAFAEL DISTRICT PERMANENT
DEPARTMENT OF EDUCATION REGULAR
7/1/2009 6/23/2010 CLASSROOM TEACHER I 13333.00 11-1 YES
SAN RAFAEL DISTRICT PERMANENT
DEPARTMENT OF EDUCATION REGULAR
1/5/2009 6/30/2009 CLASSROOM TEACHER I 12026.00 10-1 YES
SAN RAFAEL DISTRICT PERMANENT
DEPARTMENT OF EDUCATION
6/10/2008 12/31/2008 CLASSROOM TEACHER I 9939.00 10-1 CONTRACTUAL YES
SAN RAFAEL DISTRICT
DEPARTMENT OF EDUCATION
1/3/2008 3/28/2008 CLASSROOM TEACHER I 9939.00 10-1 CONTRACTUAL YES
SAN RAFAEL DISTRICT
DEPARTMENT OF EDUCATION
6/14/2007 12/31/2007 CLASSROOM TEACHER I 9939.00 10-1 CONTRACTUAL YES
SAN RAFAEL DISTRICT
DEPARTMENT OF EDUCATION
1/3/2007 3/31/2007 CLASSROOM TEACHER I 9939.00 10-1 CONTRACTUAL YES
SAN RAFAEL DISTRICT
DEPARTMENT OF EDUCATION
7/6/2006 12/31/2006 CLASSROOM TEACHER I 9939.00 10-1 CONTRACTUAL YES
SAN RAFAEL DISTRICT
DEPARTMENT OF EDUCATION
11/14/2005 12/16/2005 CLASSROOM TEACHER I 9939.00 10-1 CONTRACTUAL YES
SAN JOSE DEL MONTE CITY
DEPARTMENT OF EDUCATION
9/3/2005 10/31/2005 CLASSROOM TEACHER I 9939.00 10-1 CONTRACTUAL YES
SAN JOSE DEL MONTE CITY
DEPARTMENT OF EDUCATION
7/31/2005 9/31/2005 CLASSROOM TEACHER I 9939.00 10-1 CONTRACTUAL YES
SAN JOSE DEL MONTE CITY
N/A N/A N/A N/A NA NA NA NA

N/A N/A N/A N/A NA NA NA NA

N/A N/A N/A N/A NA NA NA NA

N/A N/A N/A N/A NA NA NA NA

N/A N/A N/A N/A NA NA NA NA

N/A N/A N/A N/A NA NA NA NA

N/A N/A N/A N/A NA NA NA NA

N/A N/A N/A N/A NA NA NA NA

N/A N/A N/A N/A NA NA NA NA

N/A N/A N/A N/A NA NA NA NA

N/A N/A N/A N/A NA NA NA NA

(Continue on separate sheet if necessary)

SIGNATURE DATE 4/27/2017 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 POSITIO
From To

N/A N/A NA N/A

N/A N/A NA N/A

N/A N/A NA N/A

N/A N/A NA N/A

N/A N/A NA N/A

N/A N/A NA N/A

N/A N/A NA 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
2016 DIVISION TRAINING-WORKSHOP ON IMPROVEMENT OF ELEMENTARY DEPARTME
12/5/2016 12/7/2016 24 HOURS TECHNICAL
SCHOOL ACADEMIC PERFORMANCE IN MATHEMATICS
BOYS SCO
RESOURCE SPEAKER IN THE 2016 DISTRICT BSP ENCAMPMENT 10/24/2016 10/25/2016 16 HOURS TECHNICAL

DISTRICT ECHO CONFERENCE-WORKSHOP ON THE PREPARATION OF DEPARTME

9/21/2016 9/23/2016 24 HOURS TECHNICAL
RESEARCH PROPOSAL AND FINAL REASEARCH OUTPUTS
2016 DISRICT ADVANCE TRAINING ON THE CONTENTS AND STRATEGIES FOR DEPARTME
9/7/2016 9/9/2016 24 HOURS TECHNICAL
SELECT ELEMENTARY MATHEMATICS TEACHERS
DIVISION WRITESHOP ON THE PREPARATION OF DAILY LESSON LOG (DLL), DEPARTME
8/2/2016 8/4/2016 24 HOURS TECHNICAL
LEARNING AND PROGRESS RESEARCH MATERIALS FOR EPP
DIVISION ORIENTATION/BRIEFING OF RECIFIENT PUBLIC ELEMENTARY AND DEPARTME
7/14/2016 7/14/2016 8 HOURS TECHNICAL
SECONDARY SCHOOLS UNDER THE DEPED COMPUTERIZATION PROGRAM
DEPARTME
JOINT DISTRICT TRAINING-WORKSHOP ON BASIC TROUBLESHOOTING,FORMATING AND
NETWORKING OF DCP PACKAGES USING WINDOWS MULTIPOINT SERVER
7/28/2016 7/30/2016 24 HOURS TECHNICAL

DEPARTME
DISTRICT IN-SERVICE TRAINING (INSET) FOR TEACHERS 6/8/2016 6/10/2016 24 HOURS TECHNICAL

DEPARTME
DISTRICT CASCADING OF K TO 12 TRAINING OF GRADE 5 TEACHERS 5/16/2016 5/20/2016 40 HOURS TECHNICAL

DEPARTME
K TO 12 TRAINING OF GRADE 5 TEACHERS 4/18/2016 4/24/2016 48 HOURS TECHNICAL

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

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

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

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

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

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

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

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

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

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

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

(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 N/A

BAKING N/A

GARDENING N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE 4/27/2017

/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

N/A

N/A

N/A

N/A

N/A

N/A

N/A
separate sheet if necessary)

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

CONDUCTED/ SPONSORED BY
(Write in full)

DEPARTMENT OF EDUCATION
DIVISION OF BULACAN
BOYS SCOUTS OF THE PHILIPPINES
PANDI NORTH DISTRICT
DEPARTMENT OF EDUCATION
SAN RAFAEL WEST DISTRICT
DEPARTMENT OF EDUCATION
SAN RAFAEL WEST DISTRICT
DEPARTMENT OF EDUCATION
DIVISION OF BULACAN
DEPARTMENT OF EDUCATION
DIVISION OF BULACAN
DEPARTMENT OF EDUCATION
SAN RAFAEL EAST AND WEST
DISTRICT
DEPARTMENT OF EDUCATION
SAN RAFAEL WEST DISTRICT
DEPARTMENT OF EDUCATION
SAN RAFAEL WEST DISTRICT
DEPARTMENT OF EDUCATION
DIVISION OF BULACAN

N/A

N/A

N/A

N/A
 N/A

N/A

N/A

N/A

N/A

N/A

N/A

separate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in full)

N/A

N/A

N/A

N/A

N/A

N/A

N/A
separate sheet if necessary)

4/27/2017 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:
________________________________

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 by NO
YES ✘
any court or tribunal?
If YES, give details:
________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation, retirement, YES ✘ NO
dropped from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in If YES, give details:
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 take
the last 6 m
AUREA F. LAJOM, Ed.D. POBLACION, SAN RAFAEL, BULACAN 0925 311 0824 3.5 cm. X 4
(passport s

GENEROSA A. CRUZ CONCEPCION, BALIUAG, BULACAN 0933 520 5258 With full and ha
name tag and sig
printed na
RUEL B. SANTIAGO SAMPALOC, SAN RAFAEL, BULACAN 0925 625 1664
Computer gen
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete or photocopied
is not accep
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 administrative/criminal case/s PHOTO
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: P ROFESSIONAL REGULATION COMMISSION

ID/License/Passport No.: 0860073

Signature (Sign inside the box)
4/27/2017
Date/Place of Issuance: 11/24/2004/SAMPALOC, MANILA
Date Accomplished Right Thumb

SUBSCRIBED AND SWORN to before me this RAFAEL L. GONGON , affiant exhibiting his/her validly issued government ID as indicated above.

CECILIA E. VALDERAMA, Ph.D.

Person Administering Oath

CS FORM 21
 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

GONGON , affiant exhibiting his/her validly issued government ID as indicated above.

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