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 ORTIZ
NAME EXTENSION (JR., SR
FIRST NAME MARK JOHN
MIDDLE NAME GARCIA
3. DATE OF BIRTH
(mm/dd/yyyy) 4/25/1986 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH San Antonio , Nueva Ecija If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS 312 S. VE

Widowed Separated
House/Block/Lot No. S
SAL
Other/s:
Subdivision/Village Ba
7. HEIGHT (m) 5'6 CITY OF SAN JUAN N
City/Municipality Pr
8. WEIGHT (kg) 84 KG ZIP CODE 1500

18. PERMANENT ADDRESS

9. BLOOD TYPE O
House/Block/Lot No. S

10. GSIS ID NO.

Subdivision/Village Ba
11. PAG-IBIG ID NO. 1210-8788-7466

12. PHILHEALTH NO. 01-051339971-0 ZIP CODE City/Municipality Pr

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 267-178-956 20. MOBILE NO. 09174184331

15. AGENCY EMPLOYEE NO.
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME
FIRST NAME
MIDDLE NAME
4699235 21. E-MAIL ADDRESS (if any) ken_28_kazama@yahoo.com
ORTIZ 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
LADY CHERYL CODY GABRIEL M. ORTIZ
MASANGKAY

OCCUPATION TEACHER

EMPLOYER/BUSINESS NAME DEP-ED SAN JUAN

BUSINESS ADDRESS PINAGLABANAN, SAN JUAN

TELEPHONE NO. 9055997337

24. FATHER'S SURNAME ORTIZ

NAME EXTENSION (JR., SR)
FIRST NAME MARK JOHN

MIDDLE NAME PASCUAL

25. MOTHER'S MAIDEN NAME JEVA

SURNAME ORTIZ

FIRST NAME MERCILINA

MIDDLE NAME GARCIA (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)
 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

PEDRO GUEVARRA ELEMNTARY June March

ELEMENTARY Graduate
SCHOOL 1993 1999
June March
SECONDARY /
VOCATIONAL SAN ANTON NATIONAL HIGHSCHOOL Graduate
1999 2004
FOOD, BEVERAGES AND Sept
TESDA Nov 2015 Graduate
SERVICES 2015
TRADE
June Oct.
COURSE
COLLEGE THE NATIONAL TEACHERS COLLEGE BEED Graduate
2009 2013
June . PRESEN
PUP COLLEGE OF LAW JURIS DOCTOR 50 units
2015 T

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM
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)

Dual Citizenship

by naturalization
Pls. indicate country:

S. VELOSO
Street
SALAPAN
Barangay
NCR
Province
1500

Street

Barangay

Province

09174184331

ken_28_kazama@yahoo.com

DATE OF BIRTH (mm/dd/yyyy)

JAN. 09, 2017

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC HONORS
GRADUATED
RECEIVED
 SCHOLARSHIP/
YEAR
ACADEMIC HONORS
GRADUATED
RECEIVED

March 1999

March 2004

June 2003

May 2009

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 SPECIAL DATE OF
RATING
LAWS/ CES/ CSEE BARANGAY EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable)
ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

LET 84.00% 3/29/2015 STA MESA, MANILA

(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
(Write in full/Do not (Write in SALARY
applicable)& STEP
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To

7/10/2017 Present Teacher - I Salapan Elementary School 19, 200

04/13/2015 04/10/2017 Teacher Faith Christian School 15,000

 (Continue on separate sheet if necessary)

SIGNATURE DATE
 LICENSE (if applicable)

NUMBER Date of
Validity

1389699 April 2019

e on separate sheet if necessary)

of duties should be indicated in the attached Work Experience sheet. GOV'T

SERVICE

STATUS OF
APPOINTMENT

(Y/
N)
Regular Yes

Contractual No
e on separate sheet if necessary)
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 POSI
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/ CONDU
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/
Technical/etc)
From To
EMPOWERING MATH TEACHERS FOR K-12 BASIC EDUCATION 10/27/2017 10/29/2017 72.0
CURRICULUM
MTAP -DEP-ED-NCR SEMINAR WORKSHOP IN MATHEMATICS 09/30/2017 10/01/2017 72.0

(Continue on separate sheet if necessary)

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

Highly analytical skilled

Capable in Microsoft Word, Excel, Powerpoint and

Access to Internet and World Wide Web

(Continue on separate sheet if necessary)

SIGNATURE DATE
PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

separate sheet if necessary)

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

CONDUCTED/ SPONSORED BY
(Write in full)

separate sheet if necessary)

 MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

separate 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 ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘

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? RESIGNATION
________________________________
________________________________
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.

11 S. Veloso St., Bgy. Salapan, City of

LLOYD T. TULAYLAY San Juan
0947.222.14.88

42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct 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 filing of ORTIZ, MARK JOHN G.
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: Pag-Ibig

ID/License/Passport No.: 1210-8788-7466

Signature (Sign inside the box)
JANUARY ___, 2018
Date/Place of Issuance: 2017/ CAINTA
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this JANUARY __, 2018 , 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