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 CABASOY
NAME EXTENSION (JR., SR)
FIRST NAME MELY
MIDDLE NAME BADAY
3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 7/10/1974 ✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH APANG, ALILEM, ILOCOS SUR If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS

Widowed Separated House/Block/Lot No. Street

Other/s: ANAAO
Subdivision/Village Barangay
7. HEIGHT (m) 1.45 ALILEM ILOCOS SUR
City/Municipality Province
8. WEIGHT (kg) 53 ZIP CODE 2716
18. PERMANENT ADDRESS
9. BLOOD TYPE O
House/Block/Lot No. Street

10. GSIS ID NO. 2003737592 ANAAO

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1210-1158-1520 ALILEM ILOCOS SUR

City/Municipality Province

12. PHILHEALTH NO. 050000864398 ZIP CODE 2716

13. SSS NO. N/A 19. TELEPHONE NO. N/A
14. TIN NO. 940-716-842 20. MOBILE NO. 09098149620
15. AGENCY EMPLOYEE NO. 4198945 21. E-MAIL ADDRESS (if any) mely.cabasoy @deped.gov.ph
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME CABASOY 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
N/A
FIRST NAME APOLINARIO NORELYN B. CABASOY 2/8/2003
MIDDLE NAME PAGULI ALLENMAY B. CABASOY 01/ 08/ 2007
OCCUPATION FARMING MARK ANGELO B. CABASOY 5/5/2012
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME BADAY
N/A
FIRST NAME ABUTEN
MIDDLE NAME MAYYAS
25. MOTHER'S MAIDEN NAME

SURNAME UGALDE
FIRST NAME CANNAY
MIDDLE NAME APUPOT (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

W/honor,special
ELEMENTARY Alilem Central School Elementary 1984 1989 N/A 1989 award

W/honor,special
SECONDARY
VOCATIONAL / Alilem National High School High School 1989 1993 N/A 1993 award

La Union Vocational School Dressmaking 1994 1995 N/A N/A N/A

TRADE
Bachelor of Secondary
COURSE
COLLEGE Trinity College of Quezon City 1997 2002 N/A 1988 SFIC Scholarship
Education
University of Northern Master of Arts in Teaching
GRADUATE STUDIES 2017 2019 30 N/A n/a
Philippines Filipino
(Continue on separate sheet if necessary)

SIGNATURE DATE July 19, 2019

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 75.60 8/25/2002 Kamuning Elementary School 0775951 7/10/2022

(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)
1/1/2019 to present Teacher I Department of Education 21,038.00 11-2 Reg.Permanent YES
10/19/2018 12/31/2018 Teacher I Department of Education 20,437.00 11-2 Reg.Permanent YES

01/01/2018 10/18/2018 Teacher I Department of Education 20,437.00 11-2 Reg.Permanent YES

01/01/2017 12/31/2017 Teacher I Department of Education 19,620.00 11-1 Reg.Permanent YES

01/01/2016 12/31/2016 Teacher I Department of Education 18,077.00 12-1 Reg.Permanent YES

10/19/2015 12/31/2015 Teacher I Department of Education 18,549.00 11-1 Reg.Permanent YES

10/19/2012 10/18/2015 Teacher I Department of Education 18,549.00 11-1 Reg.Permanent YES

10/02/2009 10/18/2012 Secondary School Teacher LGU, Alilem Ilocos Sur 6,000.00 CASUAL YES

(Continue on separate sheet if necessary)

SIGNATURE DATE July 19, 2019
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

Rural Improvement Club ( RIC) 04/23/2003 to present Treasurer

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

7/3/2019 7/5/2019 24 Department of Education

Pandibisyong Pagsasanay
ReorganizationLearning Estratehiya
Area sa Pagtuturo
Coordinatoal Meeting &ng Filipi
Planning Conference of Subject/Learning Area 06/30/2019 06/30/2019 8 Department of Education
Coordinators
Pambansang Samahan ng mga Tagamasid at
04/16/2018 04/20/2018 40 Tagapagtaguyod sa Filipino (PASATAF)
Pambansang Seminar Gawaing-Kapulungan sa Filipino
Sining ng Pantanghalan,Estratehiya sa Pagtuturo at 10/3/2017 10/3/2017 8 Pisara Publishing
Classroom Management
K-12 Assessment National Seminar Workshop in Phil. Basic 01/25/2014 01/27/2014 24 Philippine Association for the Career
Education Advancement of Educators (PACAE)

05/25/2016 05/27/2016 24 Department of Science &Technology

Computer Skills Enhancement Training for Teachers
Regional Mass Training for Grade 9 Filipino Teachers in 05/13/2014 05/17/2014 40 Department of Education
the K-12 Curriculum
Regional Training for Grade 8 Teachers in the K-12 05/15/2013 05/17/2013 40 Department of Education
Curriculum in Filipino
Regional Training of Grade 8 Teachers for K-12 Curriculum 05/20/2013 05/24/2013 40 Department of Education
in Edukasyon sa Pagpapakatao (ESP)
11/26/2013 11/26/2013 8 Lorma College
Library Innovation
Regional Mass Training of Second Year Teachers
05/10/2011 05/13/2011 32 Department of Education
Mass Training of First Year Teachers on The Secondary
Education Curriculum 10/26/2010 10/29/2010 32 Technical Department of Education

(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)

Gardening/ planting N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE July 19, 2019

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? ________________________________
________________________________
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: BAGO
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
DUMMAO, TRIFINA B. POBLACION, ALILEM, ILOCOS SUR 9173412348 3.5 cm. X 4.5 cm
(passport size)

TIGLAO,HILDEGARDE M. POBLACION, ALILEM, ILOCOS SUR 9461922091 With full and handwritten
name tag and signature over
printed name
BUDAO, ANTONIO S. ANAAO, ALILEM, ILOCOS SUR 9398752523
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: PRC
ID/License/Passport No.: 0775951 Signature (Sign inside the box)
July 19/2019
Date/Place of Issuance: 01/19/2019 - BAGUIO CITY Date Accomplished Right Thumbmark

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

ROMEO S. VENANCIO
Person Administering Oath

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