CS Form No.

212

PERSONAL DATA SHEET

Revised 2017

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 ACCOM PLISHING 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 ESTRONIMO
NA M E EXTENSION (JR., SR)
FIRST NAME LAARNI N/A

MIDDLE NAME MARIANO

3. DATE OF BIRTH
9/2/1995 16. CITIZENSHIP
Filipino Dual Citizenship
(mm/dd/y y y y )
by birth by naturalization
4. PLACE OF BIRTH SANTIAGO, ALIAGA, NUEVA ECIJA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female

Single Married 17. RESIDENTIAL ADDRESS #91 PUROK 2

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
SANTIAGO
Other/s:
Subdivision/Village Barangay
ALIAGA NUEVA ECIJA
7. HEIGHT (m) .127
City/Municipality Province
8. WEIGHT (kg) 35 ZIP CODE 3111
18. PERMANENT ADDRESS #91 PUROK 2
9. BLOOD TYPE O+
House/Block/Lot No. Street
10. GSIS ID NO. N/A SANTIAGO
Subdivision/Village Barangay
ALIAGA NUEVA ECIJA
11. PAG-IBIG ID NO. N/A
City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 3111

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

14. TIN NO. N/A 20. MOBILE NO. 09352366745

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any ) estronimo@yahoo.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/y y y y )
NA M E EXTENSION (JR., SR)
FIRST NAME N/A N/A N/A N/A

MIDDLE NAME N/A N/A N/A

OCCUPATION N/A N/A N/A

EMPLOYER/BUSINESS NAME N/A N/A N/A

BUSINESS ADDRESS N/A N/A N/A

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

24. FATHER'S SURNAME ESTRONIMO

NA M E EXTENSION (JR., SR)
FIRST NAME HILARIO N/A

MIDDLE NAME NUES

25. MOTHER'S MAIDEN NAME

SURNAME MARIANO

FIRST NAME LAURA

MIDDLE NAME ROXAS (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

P ERIOD OF
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE HIGHEST LEVEL/ YEA R SCHOLA RSHIP /
LEVEL A TTENDA NCE UNITS EA RNED GRA DUA TE A CA DEM IC HONORS
(Write in full) (Write in full) (if no t graduated) D RECEIVED
From To

ELEMENTARY SANTIAGO ELEMENTARY SCHOOL ELEMENTARY 2002 2008 GRADUATED 2008 SALUTATORIAN

7TH HONORABLE
SECONDARY ALIAGA NATIONAL HIGH SCHOOL HIGH SCHOOL 2008 2012 GRADUATED 2012
MENTION

VOCATIONAL /
N/A N/A N/A N/A N/A N/A N/A
TRADE COURSE

BACHELOR OF SECONDARY
COLLEGE CENTRAL LUZON STATE UNIVERSITY 2012 2016 GRADUATED 2016 N/A
EDUCATION

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE December 5, 2018 CS FORM 212 (Rev ised 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 Date of
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT Validity
PROFESSIONAL BOARD EXAMINATION FOR
78.80 09/25/2016 BAGUIO CITY 1497085 9/2/2019
TEACHERS

(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.
SALARY/ JOB/
28. INCLUSIVE DATES PAY GRADE (if
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY M ONTHLY GOV'T
(mm/dd/y y y y ) applicable)& STA TUS OF
SERVICE
(Write in full/Do not abbrev iate) (Write in full/Do not abbrev iate) SA LA RY STEP (Format A P P OINTM ENT
(Y/ N)
" 00-0" )/
From To INCREM ENT

06/13/2017 PRESENT TEACHER ALIAGA BRIGHT MINDS ACADEMY, INC. ₱6, 800.00 N/A CONTRACTUAL NO

(Continue on separate sheet if necessary)

SIGNATURE DATE 12-05-2018 CS FORM 212 (Revised 2017), Page 2 of 4

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. NUM BER OF
(Write in full) (mm/dd/y y y y ) HOURS
POSITION / NATURE OF WORK
From To
CLSU, SINAG FILIPINO ( SIRKULO NG MGA
6/10/2015 4/20/2016 MEMBER
NAGDADALUBHASA SA FILIPINO )

(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)
TITLE OF LEARNING AND DEVELOPMENT INCLUSIVE DATES OF Type o f LD
30. NUM BER OF ( M anagerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE HOURS Superviso ry/ (Write in full)
(Write in full) From To Technical/etc)

EVENTS MANAGEMENT SERVICES NCIII 04/06/2018 05/05/2018 108 NUEVA ECIJA INSTITUTE OF FOREIGN LANGUAGE

PALIHAN SA KURIKULUM NG K-12 SA FILIPINO 11/23/2015 11/23/2015 9 CLSU, CAS - DEPARTAMENTO NG FILIPINO
PROJECT SIT-IN TRANSFORMING MINDSET,
12/02/2014 12/02/2014 3 CLSU-USSC
REFINING OUTLOOK#INTEGRITY

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 33.
(Write in full) (Write in full)
N/A N/A
COMPUTER LITERATE
COOKING

DANCING

READING

(Continue on separate sheet if necessary)

SIGNATURE DATE 12-05-2018

CS FORM 212 (Revised 2017), P age 3 o f 4

34. Are you related by consanguinity or affinity to the appointing or recommending authority, or
chief of bureau or office or to the person who has immediate supervision over you in the
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 YES NO
regulation 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 If YES, give details:
phased 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 YES NO
(except Barangay election)? If YES, give details:

b. Have you resigned from the government service during the three (3)-month period YES NO
before the last 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
a following
Are you aitems:
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
BRGY. SANTIAGO, ALIAGA, the last 6 months
RENANTE PASCUAL N/A 3.5 cm. X 4.5 cm
NUEVA ECIJA (passport size)
BRGY. SANTIAGO, ALIAGA,
ROEBELL A. DAGA N/A With f ull and handwritten
NUEVA ECIJA name tag and signature ov er
printed name
MARICEL A. DIMAALA SAN JOSE CITY, NUEVA ECIJA N/A
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct or photocopied picture
is not acceptable
and 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 PHOTO
filing of administrative/criminal case/s against me.

Government Issued ID (i.e.P asspo rt, GSIS, SSS, P RC, Driver's

License, etc.) PLEASE INDICATE ID Number
Gov ernment Issued ID: PRC

ID/License/Passport No.: 1497085

Signature (Sign inside the box )
12-15-2018
Date/Place of Issuance: 12/10/2016
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), P age 4 o f 4