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 POLCA
NAME EXTENSION (JR., SR) N/A
FIRST NAME RHYS GWYNETH

MIDDLE NAME ORDILLOS

3. DATE OF BIRTH
1/10/1995 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH TAMAG, VIGAN CITY, ILOCOS SUR If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

✘ Single Married 17. RESIDENTIAL ADDRESS

6 CIVIL STATUS
House/Block/Lot No. Street
Widowed Separated
CAMESTIZOAN
Other/s: Subdivision/Village Barangay

7. HEIGHT (m) 1.47 SANTO DOMINGO ILOCOS SUR

City/Municipality Province
8. WEIGHT (kg) 43 ZIP CODE 2729
18. PERMANENT ADDRESS
9. BLOOD TYPE B+
House/Block/Lot No. Street

10. GSIS ID NO. N/A CAMESTIZOAN

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121143297712 SANTO DOMINGO ILOCOS SUR

City/Municipality Province

12. PHILHEALTH NO. 05-025541121-4 ZIP CODE 2729

13. SSS NO. 01-2473126-8 19. TELEPHONE NO. N/A

14. TIN NO. 462-512-853-000 20. MOBILE NO. 0936-681-8267

15. AGENCY EMPLOYEE NO. 4220282 21. E-MAIL ADDRESS (if any) RHYSGWYNETHPOLCA@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/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME N/A
MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME POLCA

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

MIDDLE NAME TABAYAAY

25. MOTHER'S MAIDEN NAME

SURNAME ORDILLOS

FIRST NAME GENALYN

MIDDLE NAME BARCENA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY STO. DOMINGO SOUTH CENTRAL SCHOOL ELEMENTARY 2001 2007 GRADUATED 2007 SALUTATORIAN

8TH HONORABLE
SECONDARY /
VOCATIONAL BENITO SOLIVEN ACADEMY HIGH SCHOOL 2007 2011 GRADUATED 2011 MENTION

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

TRADE BACHELOR OF SCIENCE IN BUSINESS PROVINCIAL/COLLEGE

COURSE
COLLEGE UNIVERSITY OF NORTHERN PHILIPPINES ADMINISTRATION MAJOR IN MANAGEMENT 2011 2015 GRADUATED 2015 SCHOLARSHIP/DEAN'S
LISTER
ACCOUNTING

GRADUATE STUDIES UNIVERSITY OF NORTHERN PHILIPPINES MASTER OF BUSINESS ADMINISTRATION 2017 2019 30 UNITS N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 27, 2020

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 PROFESSIONAL ELIGIBILITY 82.36% 10/26/2014 ILOCOS SUR NATIONAL HIGH SCHOOL 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.
GOV'T
28. INCLUSIVE DATES SALARY/ JOB/ PAY 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)
ADMINISTRATIVE ASSISTANT III/ SENIOR DEPARTMENT OF EDUCATION / ALILEM
1/1/2020 PRESENT PHP 18,763.00 09-1 PERMANENT YES
BOOKKEEPER NATIONAL HIGH SCHOOL
ADMINISTRATIVE ASSISTANT III/ SENIOR DEPARTMENT OF EDUCATION / ALILEM
1/1/2019 12/31/2019 PHP 17,975.00 09-1 PERMANENT YES
BOOKKEEPER NATIONAL HIGH SCHOOL
ADMINISTRATIVE ASSISTANT III/ SENIOR DEPARTMENT OF EDUCATION / ALILEM
6/9/2018 12/31/2018 PHP 17,473.00 09-1 PERMANENT YES
BOOKKEEPER NATIONAL HIGH SCHOOL
8/2/2017 07/21/2017 ACCOUNTING STAFF BSC REALTY, INC. PHP 13,000.00 N/A PROBATION NO

01/25/2016 09/15/2016 BRANCH ACCOUNTANT MAKARI ROTARY 3H RESOURCES, INC. PHP 10,000.00 N/A REGULAR NO
 (Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 27, 2020

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

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

ENHANCEMENT TRAINING FOR NON-TEACHING PERSONNEL 12/05/2019 12/05/2019 8 TECHNICAL SCHOOLS DIVISION OF ILOCOS SUR

13TH NATIONAL CONGRESS AND SEMINAR-WORKSHOP OF THE DEPARTMENT DEPARTMENT OF EDUCATION NATIONAL
12/25/2019 12/27/2019 24 TECHNICAL
OF EDUCATION - NATIONAL EMPLOYEES UNION EMPLOYEES' UNION

CERTIFIED ACCOUNTING TECHNICIAN 04/19/2015 04/26/2015 16 TECHNICAL BAGUIO INSTITUTE OF PROFESSIONALS, INC.

(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)

N/A N/A N/A

 (Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 27, 2020

 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.

ID picture taken within
the last 6 months
ROMEO S. VENANCIO CAOAYAN, SUGPON, ILOCOS SUR 0917-177-3256 3.5 cm. X 4.5 cm
(passport size)

LIRIO V A. PURUGGANAN SAN PEDRO, VIGAN CITY, ILOCOS SUR 0955-833-0013 With full and handwritten
name tag and signature over
printed name
HILDEGARDE M. TIGLAO POBLACION, ALILEM , ILOCOS SUR 0977-343-4405
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied picture
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: TIN

ID/License/Passport No.: 462-512-853-000

Signature (Sign inside the box)
JANUARY 27, 2020
Date/Place of Issuance: 01/15/2015 / BANTAY, ILOCOS SUR
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