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

MIDDLE NAME AFAGA

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 01/25/1980 Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH LINAMANAN, JONES, ISABELA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS N/A BACENA ST.
House/Block/Lot No. Street
Widowed Separated
N/A
Other/s: Subdivision/Village LINAMANAN
7. HEIGHT (m) 1.66 JONES, ISABELA
City/Municipality Province
8. WEIGHT (kg) 63 ZIP CODE 3313
9. BLOOD TYPE B
18. PERMANENT ADDRESS N/A BACENA ST.
House/Block/Lot No. Street

10. GSIS ID NO. 02004294649 N/A

Subdivision/Village LINAMANAN
11. PAG-IBIG ID NO. 134000026574 JONES, ISABELA
City/Municipality Province

12. PHILHEALTH NO. 19-089659591-2 ZIP CODE 3313

13. SSS NO. 33-7119989-6 19. TELEPHONE NO. N/A
14. TIN NO. 207-187-894-0 20. MOBILE NO. 09759331260
15. AGENCY EMPLOYEE NO. 5322393 21. E-MAIL ADDRESS (if any) shirley.gragasin001@deped.gov.ph
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME GRAGASIN 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) N/A
FIRST NAME MICHAEL MICHAEL PSALM A. GRAGASIN 07/30/2010
MIDDLE NAME BACENA DARLENE GRACE A. GRAGASIN 09/25/2013
OCCUPATION TEACHING PRINCE JETHRO A. GRAGASIN 10/18/2017
EMPLOYER/BUSINESS NAME LINAMANAN ELEMENTARY SCHOOOL
BUSINESS ADDRESS LINAMANAN, JONES, ISABELA
TELEPHONE NO. N/A
24. FATHER'S SURNAME AFAGA (DECEASED)
NAME EXTENSION (JR., SR) N/A
FIRST NAME ARGELITO
MIDDLE NAME LORENZO
25. MOTHER'S MAIDEN NAME

SURNAME DOMINGO (DECEASED)

FIRST NAME ZENAIDA
MIDDLE NAME TADEO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

CALINAOAN ELEMENTARY SCHOOL,

ELEMENTARY GRADE SCHOOL 1986 1992 GRADUATED 1992 N/A
STO.TOMAS, ISABELA
VOCATIONAL
SECONDARY /
NORTHERN ISABELA ACADEMY,
HIGH SCHOOL 1992 1996 GRADUATED 1996 N/A
STO.TOMAS, ISABELA
N/A N/A N/A N/A N/A N/A N/A
TRADE
COURSE ISABELA COLLEGES, CAUAYAN CITY COMPUTER SECRETARIAL 1997 1999 GRADUATED 1999 N/A
COLLEGE
PHILIPPINE NORMAL UNIVERSITY- BACHELOR OF SECONDARY EDUCATION
2002 2006 GRADUATED 1999 Leadership
ISABELA CAMPUS, ALICIA, ISABELA (BSE) MAJOR IN ENGLISH

NORTHEASTERN COLLEGE, SANTIAGO MASTER OF ARTS IN EDUCATION

GRADUATE STUDIES 2013 2016 GRADUATED 2016 N/A
CITY (MA.Ed)
(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER RATING DATE OF LICENSE (if applicable)
SPECIAL LAWS/ CES/ CSEE (If EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY / DRIVER'S LICENSE Applicable) CONFERMENT NUMBER Date of
Validity

LICENSURE EXAMINATION FOR TEACHERS (LET) 78.40 7/27/2006 TUGUEGARAO CITY, CAGAYAN 0938702 10/07/2006

(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/ GOV'T SERVICE
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY PAY GRADE (if
(mm/dd/yyyy) STATUS OF
MONTHLY SALARY applicable)& STEP
(Format "00-0")/ APPOINTMENT
(Write in full/Do not abbreviate) (Write in full/Do not abbreviate) INCREMENT (Y/ N)
From To

DEPARTMENT OF EDUCATION/JONES
01/01/2019 Present TEACHER-III PhP25,232.00 13-1 PERMANENT YES
WEST DISTRICT
DEPARTMENT OF EDUCATION/JONES
05/28/2018 12/31/2018 TEACHER-III PhP24,510.00 13-1 PERMANENT YES
WEST DISTRICT
DEPARTMENT OF EDUCATION/JONES
01/01/2018 05/27/2018 TEACHER-I PhP20,179.00 11-1 PERMANENT YES
WEST DISTRICT
DEPARTMENT OF EDUCATION/JONES
01/01/2017 12/31/217 TEACHER-I PhP19, 620.00 11-1 PERMANENT YES
WEST DISTRICT
DEPARTMENT OF EDUCATION/JONES
01/01/2016 12/31/2016 TEACHER-I PhP19,077.00 11-1 PERMANENT YES
WEST DISTRICT
DEPARTMENT OF EDUCATION/JONES
08/24/2015 12/31/2015 TEACHER-I PhP18,549.00 11-1 PERMANENT YES
WEST DISTRICT
DEPARTMENT OF
06/05/2015 08/23/2015 TEACHER-III PhP21,436.00 13-1 PERMANENT YES
EDUCATION/AGLIPAY HIGH SCHOOL
DEPARTMENT OF 11
01/04/2013 06/04/2015 TEACHER-I PhP18,549.00 PERMANENT YES
EDUCATION/AGLIPAY HIGH SCHOOL
DEPARTMENT OF
01/03/2012 03/31/2012 TEACHER-I PhP10,274.00 N/A CASUAL YES
EDUCATION/AGLIPAY HIGH SCHOOL
DEPARTMENT OF EDUCATION/JONES
06/06/2011 12/31/2011 TEACHER-I PhP15,065.00 11-1 SUBSTITUTE YES
WEST DISTRICT
CENTRAL ISABELA CHRISTIAN
06/11/2008 03/31/2008 CLASSROOM TEACHER PhP7,500.00 N/A REGULAR NO
ACADEMY, ILAGAN CITY
UNIVERSITY OF MANILA,
07/02/2007 10/30/2007 ENGLISH TEACHER PhP8,000.00 N/A PROBATIONARY NO
INTERNATIONAL LANGUAGE SCHOOL
MERRY SUNSHINE MONTESSORI
06/03/2006 04/05/2007 CLASSROOM TEACHER PhP5,500.00 N/A PROBATIONARY NO
SCHOOL, CAUAYAN CITY

(Continue on separate sheet if necessary)

SIGNATURE DATE AUGUST 1, 2018

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 NUMBER OF
(Write in full) (mm/dd/yyyy) HOURS POSITION / NATURE OF WORK
From To
DAILY VACATION BIBLE SCHOOL (DVBS), CHURCH OF GOD, WORLD MISSION
4/24/2019 4/28/2019 32.0 TEACHER
OF THE PHILIPPINES, LINAMANAN, JONES, ISABELA
WORDA, LINAMANAN CHURCH OF GOD WORLD MISSION OF THE PHILIPPINES,
9/1/2016 PRESENT N/A WORSHIP HEAD
LINAMANAN, JONES, ISABELA

COMMUNITY SERVICES, LINAMANAN, JONES, ISABELA 6/1/2019 PRESENT N/A TEACHER COORDINATOR

BRIGADA ESKWELA 2018, LINAMANAN ELEMENTARY SCHOOL 5/18/2018 5/22/2018 40.0 B E Committee Chairman

NATIONAL WORSHIP CAMP, CAVITE PROVINCE 4/23/2016 4/27/2016 40.0 Participant

(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 three (3) years for Division Chief/Executive/Managerial positions)
INCLUSIVE DATES OF
ATTENDANCE Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS NUMBER OF ( Managerial/ CONDUCTED/ SPONSORED BY
(Write in full) (mm/dd/yyyy)
HOURS Supervisory/ (Write in full)
Technical/etc)
From To

2019 DISTRICT BSP CAMP O'RAL AND GSP ENCAMPMENT 10/17/2019 10/19/2019 24.0 TECHNICAL DEPARTMENT OF EDUCATION
INTENSIVE TRAINING AND WRITESHOP FOR 2019 REGIONAL SCHOOLS PRESS
10/09/2019 10/11/2019 24.0 TECHNICAL DEPARTMENT OF EDUCATION
CONFERENCE QUALIFIERS
2019 DIVISION SCHOOLS PRESS CONFERENCE 09/18/2019 09/21/2019 24.0 TECHNICAL DEPARTMENT OF EDUCATION

2019 AREA SCHOOLS PRESS CONFERENCE 08/10/2019 08/10/2019 8.0 TECHNICAL DEPARTMENT OF EDUCATION
2019 CAMPUS JOURNALISM SEMINAR-WORKSHOP CUM SPA CAPACITY
07/13/2019 07/14/2019 16.0 PARTICIPANT DEPARTMENT OF EDUCATION
ENHANCEMENT TRAINING
SCHOOL-BASED IN-SERVICE TRAINING FOR TEACHERS 05/29/2019 05/31/2019 24.0 TECHNICAL DEPARTMENT OF EDUCATION

DISTRICT RPMS-PPST TRAINING 05/15/2019 05/16/2019 16.0 PARTICIPANT DEPARTMENT OF EDUCATION

2018 REGIONAL SCHOOLS PRESS CONFERENCE 11/17/2018 11/19/2018 24.0 PARTICIPANT DEPARTMENT OF EDUCATION

2018 BSP CAMP O'RAL AND JUNIOR ENCAMPMENT 11/15/2018 11/17/2018 24.0 TECHNICAL DEPARTMENT OF EDUCATION
DISTRICT ORIENTATION-WORKSHOP ON THE UPLOADING AND VALIDATION OF
11/15/2018 11/15/2018 8.0 PARTICIPANT DEPARTMENT OF EDUCATION
DATA IN THE EBEIS
LIVE-IN CRITIQUING AND WRITESOP FOR 2018 RSPC QUALIFIERS 11/07/2018 11/09/2018 24.0 TECHNICAL DEPARTMENT OF EDUCATION

2018 DISTRICT MID-YEAR IN-SERVICE TRAINING (INSET) 10/22/2019 10/24/2018 24.0 PARTICIPANT DEPARTMENT OF EDUCATION

2018 DIVISION SCHOOLS PRESS CONFERENCE 10/11/2018 10/13/2018 24.0 TECHNICAL DEPARTMENT OF EDUCATION

2018 DISTRICT SCHOOLS PRESS CONFERENCE 09/28/2018 08/28/2018 24.0 PARTICIPANT DEPARTMENT OF EDUCATION

DISTRICT SCIENCE CAMP 2018 09/27/2018 08/27/2018 8.0 PARTICIPANT DEPARTMENT OF EDUCATION

DISTRICT ROLL-OUT IN CAMPUS PAPER PRODUCTION 09/06/2018 08/27/2018 16.0 PARTICIPANT DEPARTMENT OF EDUCATION

DIVISION LIVE-IN SEMINAR WORKSHOP IN CAMPUS PAPER PRODUCTION 7/26/2018 7/28/2018 24.0 PARTICIPANT DEPARTMENT OF EDUCATION
DISTRICT ROLL-OUT OF THE RPMS MANUAL FOR TEACHERS AND SCHOOL HEADS
7/13/2018 7/14/2018 16.0 TECHNICAL
DEPARTMENT OF EDUCATION
DISTRICT ROLL OUT CUM SEMINAR WORKSHOP ON "PROJECT BATA"
4/20/2018 4/20/2018 8.0 PARTICIPANT
DEPARTMENT OF EDUCATION

ECHO-TRAINING ON NUTRITIONAL ASSESSMENT 6/21/2017 6/21/2017 8.0 PARTICIPANT DEPARTMENT OF EDUCATION

CLUSTER LEARNING ACTION CELLS 6/2/2017 6/2/2017 8.0 PARTICIPANT DEPARTMENT OF EDUCATION

2016 DIVISION SCHOOLS PRESS CONFERENCE 11/21/2016 11/25/2016 40.0 PARTICIPANT DEPARTMENT OF EDUCATION

DISTRICT SEMINAR-WORKSHOP ON CAMPUS JOURNALISM 11/16/2016 11/17/2016 16.0 TECHNICAL

DEPARTMENT OF EDUCATION

DIVISION TRAINING OF WRITERS ON LOCAL HISTORY 3/15/2016 3/16/2016 16.0 PARTICIPANT DEPARTMENT OF EDUCATION

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full) (Write in
full)
ISABELA ASSOCIATION FOR PUBLIC
COMPUTER LITERATE CHAMPION AS A COACH/PAPER ADVISER ON CAMPUS JOURNALISM
SCHOOL TEACHERS
JONES ASSOCIATION FOR
SINGING RESOURCE SPEAKER/FACILITATOR ON CAMPUS JOURNALISM ELEMENTARY PUBLIC SCHOOL
TEACHERS
JONES ASSOCIATION FOR
ORAL AND WRITTEN COMMUNICATIVELY
GUEST SPEAKER DURING GRADUATION ELEMENTARY PUBLIC SCHOOL
COMPETENT
TEACHERS
ISABELA ASSOCIATION FOR SCHOOL
NEWSPAPERING
PAPER ADVISERS
THE GREAT SHEPHERD
(Continue on separate sheet if necessary)

SIGNATURE DATE
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 ✘ 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? To apply in the government service
________________________________
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 before the YES ✘ NO
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 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
ZENAIDA D. CRISTOBAL PUNGPONGAN, JONES, ISABELA 9161830204 3.5 cm. X 4.5 cm
(passport size)

FRANCISCA B. ALCALDE ZAMORA, CABARROGUIS, QUIRINO 9178377404 With full and handwritten
name tag and signature over
printed name
CHARITY V. RAMISCAL PROGRESO, AGLIPAY, QUIRINO 9178191732
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 LICENSE
ID/License/Passport No.: 0938702 Signature (Sign inside the box)

Date/Place of Issuance: 10/07/2006/TUGUEGARAO CITY

Date Accomplished Right Thumbmark

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

WILLIAM G. CABLINAN, JR.

Person Administering Oath

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