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 con

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

I. PERSONAL INFORMATION
2. SURNAME Cabatuan
NAME EXTENSION (JR., SR)
FIRST NAME Karen

MIDDLE NAME Untua

3. DATE OF BIRTH
(mm/dd/yyyy) 8/12/1994 16. CITIZENSHIP

4. PLACE OF BIRTH Pob. Carmen, Surigao del Sur If holder of dual citizenship, Filipino Pls. indicate coun
please indicate the details.
5. SEX Female

17. RESIDENTIAL ADDRESS

6 CIVIL STATUS Single
House/Block/Lot No.

Subdivision/Village

7. HEIGHT (m) 5"

City/Municipality
8. WEIGHT (kg) 56 ZIP CODE 8315 Poblacion,Carmen, Surigao del Sur
18. PERMANENT ADDRESS
9. BLOOD TYPE O
House/Block/Lot No.

10. GSIS ID NO.

Subdivision/Village

11. PAG-IBIG ID NO.

City/Municipality
12. PHILHEALTH NO. 18-250977956-3 ZIP CODE 8315 Pob. Carmen

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 20. MOBILE NO. 09461107794

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) esesadobo@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME Cabatuan

NAME EXTENSION (JR., SR)
FIRST NAME Domingo

MIDDLE NAME Polinar

25. MOTHER'S MAIDEN NAME

SURNAME Untua

FIRST NAME Analyn

MIDDLE NAME Lumancas (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY Carmen Central Elementary School 06/04/200 3/30/2007

VOCATIONAL /
SECONDARY Saint Michael's School 6/10/2007 3/26/2011

Bachelor of Secondary Education major in

COLLEGE TRADE Surigao del Sur State University - Cantilan 6/14/2015 4/2/2019
COURSE Technology and Livelihood Education

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE
 n concerned.

CSC use only)

R., SR)

country:

Street
Kindica
Barangay
Poblacion
Province

Street
Kindica
Barangay
Poblacion
Province
Surigao del Sur

DATE OF BIRTH (mm/dd/yyyy)

YEAR
SCHOLARSHIP/ ACADEMIC
GRADUATED
HONORS RECEIVED

2007

2011

2019 student extensionist

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 78.6 9/29/2019 Butuan City

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

(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
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (Write in
full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
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
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) Technical/etc)
From To
7 Day Skills Enhancement Training on Food and Beverage
Services
6/16/2018 9/15/2018 56 hours Extension Services and Linkages
Seminar- Workshop on Contributory Activities for Higher
11/16/2019 11/16/2019 8 hours Extension Services and Linkages
Learning Process and Professionalism

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 33.
(Write in full) (Write in
full)

(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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
________________________________

a. Have you ever been found guilty of any administrative offense?

35.

If YES, give details:

________________________________
________________________________
b. Have you been criminally charged before any court?
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 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,
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? ________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year
(except Barangay election)?
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? 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 7277); and (c) Solo Parents Welfare Act of 2000 (RA 8972), please answer the following
a.
items:
Are you a member of any indigenous group?
If YES, please specify:
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)

ID picture taken within
NAME ADDRESS TEL. NO. the last 6 months
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten

name tag and signature over
printed name

Computer generated
or photocopied picture
is not acceptable
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. 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: Voter's id

ID/License/Passport No.: 6806-0007A-H1294KUC20000

Signature (Sign inside the box)

Date/Place of Issuance: Pob. Carmen,Surigao del Sur

01/27/2020
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