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 aga
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 GALBAN
FIRST NAME MARGIE NAME EXTENSION (JR., SR

MIDDLE NAME Natividad

3. DATE OF BIRTH
(mm/dd/yyyy) 6/11/1995 16. CITIZENSHIP ✘ Filipino Dual Citizenship

by birth

4. PLACE OF BIRTH Agoo, La Union If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS 13 Villa Ve
Widowed ✘ Separated House/Block/Lot No. S
Other/s: San Agu
Subdivision/Village Ba
7. HEIGHT (m) 1.52 Agoo La U
City/Municipality Pr
8. WEIGHT (kg) 45 ZIP CODE 2504
9. BLOOD TYPE O
18. PERMANENT ADDRESS 13 Villa Ve
House/Block/Lot No. S

10. GSIS ID NO. N/A San Agu

Subdivision/Village Ba

11. PAG-IBIG ID NO. N/A Agoo

City/Municipality Pr

12. PHILHEALTH NO. 05- 250519996-0 ZIP CODE 2504

13. SSS NO. 01- 2687582-1 19. TELEPHONE NO. N/A
14. TIN NO. N/A 20. MOBILE NO. 09102821923 / 09667924
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) galbanmargie@gmail.com / margie_galban@

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 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 Galban
NAME EXTENSION (JR., SR N/A
FIRST NAME Esteban
 MIDDLE NAME Ollero
25. MOTHER'S MAIDEN NAME Marmolina U. Natividad

SURNAME Natividad
FIRST NAME Marmolina
MIDDLE NAME Ulpindo (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 Agoo East Central School N/A

Pres. Elpidio Quirino National High
SECONDARY /
VOCATIONAL N/A
School

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

TRADE
COURSE
COLLEGE
Don Mariano Marcos Memorial State University, Bachelor of Arts In Political
Mid- La Union Campus Science
Don Mariano Marcos Memorial State University,
GRADUATE STUDIES
Open University System Certificate in Teaching
(Continue on separate sheet if necessary)

SIGNATURE DATE CS FORM 212 (Re

L DATA SHEET
rience 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) N/A

Dual Citizenship

by birth by naturalization

Pls. indicate country:

Villa Verde Road

Street
San Agustin East
Barangay
La Union
Province

2504
Villa Verde Road
Street
San Agustin East
Barangay
La Union
Province

2504

N/A

09102821923 / 09667924195
galbanmargie@gmail.com / margie_galban@yahoo.com

DATE OF BIRTH (mm/dd/yyyy)

N/A
 (Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2008 with honors

2012 with honors

N/A N/A

2016 N/A

2017 N/A

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 applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity
Career Service La Union National High School, City of
81.65% 5/3/2015 N/A N/A
Examination(Professional) San Fernando
Board for Professional Teachers 86.60% 3/25/2017 University of Cordilleras, Baguio City 1646361 ###

(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 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)
6/20/2018 4/10/2019 Teacher BHC Educational Institution Inc. ### N/A contractual N/A

(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 / N
From To

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

(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/ SP
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To

Seminar on Learning Skills for Open and Distance Learners 3/25/2017 3/25/2017 8.0 N/A DMMMSU Op

On- The- Job Training 4/8/2015 5/14/2015 203.0 N/A

Campus Career and Employment Coaching for Graduating
10/1/2015 10/2/2015 16.0 N/A
Students
OJT Readiness Seminar 3/27/2015 3/27/2015 8.0 N/A

Accountability and Transpaarency 9/24/2015 9/24/2015 8.0 N/A

 (Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

communication and writing skills N/A

able to do microsoft word, powerpoint and
N/A
excel
reading books and baking N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE
PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

N/A

arate sheet if necessary)

OGRAMS ATTENDED
ive (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

DMMMSU Open University System

Office of the Provincial Assessor- Provincial
Gov't of La Union
DMMMSU- Mid La Union Campus

DMMMSU- Mid La Union Campus-

Public Administration Society

DMMMSU- Mid La Union Campus-

College of Arts and Management
arate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION

(Write in full)

N/A

N/A

N/A

arate 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? ✘ NO

b. within the fourth degree (for Local Government Unit - Career Employees)? ✘ NO

If YES, give details:

________________________________
✘ NO
35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
________________________________
✘ NO

b. Have you been criminally charged before any court?

If YES, give details:
________________________________
Date Filed:
________________________________
Status of Case/s:
✘ NO

36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation
by any court or tribunal?
If YES, give details:
________________________________
✘ NO
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation,
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? ✘ NO
________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? ✘ NO
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last
election to promote/actively campaign for a national or local candidate? ✘ NO
If YES, give details:
39. Have you acquired the status of an immigrant or permanent resident of another country?
If YES, give details (country):

40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA ✘ NO
7277); and (c) Solo Parents Welfare Act of 2000 (RA 8972), please answer the following items:
a.
✘ NO
Are you a member of any indigenous group?
If YES, please specify:
✘ NO
b. Are you a person with disability?
If YES, please specify ID No:
c. Are you a solo parent?
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
Office of the Provincial Assessor, Prov. Gov. of
Mrs. Victoria Almazan La Union
O9288347619 3.5 cm. X 4.5 cm
(passport size)
Office of the Provincial Assessor, Prov. Gov. of
Mrs. Michelle Follosco La Union
O9485494796 With full and handwritten
name tag and signature over
printed name
Ex. Brgy. Capt. Federico Estoque San Agustin East, Agoo La Union O9071880398
Computer generated
or photocopied picture
42. 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 License
ID/License/Passport No.: 1646361 Signature (Sign inside the box)

Date/Place of Issuance: 06/18/2018- 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 of

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