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 TUBALLAS

FIRST NAME ELIZABETH NAME EXTENSION (JR., SR)

MIDDLE NAME ADORA N.A

3. DATE OF BIRTH
(mm/dd/yyyy)
4/7/1981 16. CITIZENSHIP ✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH PAMBUJAN NORTHERN SAMAR If holder of dual citizenship, Pls. indicate country:

5. SEX please indicate the details.

Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS N.A N.A

Widowed Separated House/Block/Lot No. Street
BRGY.8
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 1.35m PAMBUJAN NORTHERN SAMAR
City/Municipality Province
8. WEIGHT (kg) 55 Kg ZIP CODE 6413

9. BLOOD TYPE A''

18. PERMANENT ADDRESS N.A N.A
House/Block/Lot No. Street
10. GSIS ID NO. 81070400278
BRGY.8
Subdivision/Village Barangay
PAMBUJAN NORTHERN SAMAR
11. PAG-IBIG ID NO. NONE
City/Municipality Province
12. PHILHEALTH NO. 13-00096772-7 ZIP CODE 6413

13. SSS NO. NONE 19. TELEPHONE NO. NONE

14. TIN NO. 932-143-534-000 20. MOBILE NO. 09128578282

15. AGENCY EMPLOYEE NO. 0009347 21. E-MAIL ADDRESS (if any) Elizabethadoratuballas@yahoo.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME TUBALLAS 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

NAME EXTENSION (JR., SR)

FIRST NAME RODEL JR. N/A.

MIDDLE NAME ACEDERA NONE

OCCUPATION FIRE OFFICER I
EMPLOYER/BUSINESS NAME BUREAU OF FIRE PROTECTION
BUSINESS ADDRESS MAPANAS FIRE STATION, MAPANAS NORTHERN SAMAR

TELEPHONE NO. NONE

24. FATHER'S SURNAME ADORA

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

MIDDLE NAME GORPIDO

25. MOTHER'S MAIDEN NAME

SURNAME LIPATA

FIRST NAME ESTELA

MIDDLE NAME BALUYOT (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY PAMBUJAN CENTRAL ELEMENTARY SCHOOL ELEMENTARY 6/2/1988 3/26/1994 GRADUATED 1994 NONE

VOCATIONAL 4TH HON.

SECONDARY / PAMBUJAN NATIONAL HIGH SCHOOL SECONDARY 6/5/1994 3/27/1998 GRADUATED 1998
MENTION

NONE NONE N.A N.A N.A N.A N.A

TRADE
COURSE BACHELOR OF SECONDARY EDUCATION
COLLEGE UNIVERSITY OF EASTERN PHILIPPINES 6/13/1999 4/10/2003 GRADUATED 2003 CUM LAUDE
(Major IN BIOLOGY-CHEMISTRY

MASTER OF ARTS IN EDUCATION (MAJOR IN

GRADUATE STUDIES UNIVERSITY OF EASTERN PHILIPPINES
ADMINISTRATION AND SUPERVISION)
6/15/2007 4/7/2010 GRADUATED 2010
(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 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 81.2 AUGUST 29,2003 MANILA, PHILIPPINES 0814599 4/7/2021

(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)
REGULAR/PERMA
11/23/2018 PRESENT MASTER TEACHER I DEPARTMENT OF EDUCATION-PAMBUJAN NHS 38,050 18
NENT Y

REGULAR/PERMA
2/1/2012 11/22/2018 SECONDARY SCHOOL TEACHER III DEPARTMENT OF EDUCATION-PAMBUJAN NATIO 25357 13 NENT Y

DEPARTMENT OF EDUCATION-PAMBUJAN REGULAR/PERMA

6/1/2011 01/31/21012 SECONDARY SCHOOL TEACHER II NATIONAL HIGH SCHOOL
18332 12 NENT Y

DEPARTMENT OF EDUCATION-PAMBUJAN REGULAR/PERMA

8/2/2011 5/30/2011 SECONDARY SCHOOL TEACHER II NATIONAL HIGH SCHOOL
17632 12 NENT Y
DEPARTMENT OF EDUCATION-PAMBUJAN REGULAR/PER
1/30/2009 8/1/2011 SECONDARY SCHOOL TEACHER I 14488.00 11 Y
NATIONAL HIGH SCHOOL MANENT
DEPARTMENT OF EDUCATION-PAMBUJAN REGULAR/PER
1/6/2008 6/30/2009 SECONDARY SCHOOL TEACHER I 12328.00 11 Y
NATIONAL HIGH SCHOOL MANENT
DEPARTMENT OF EDUCATION-PAMBUJAN REGULAR/PER
1/6/2008 6/30/2008 SECONDARY SCHOOL TEACHER I 11207.00 11 Y
NATIONAL HIGH SCHOOL MANENT
DEPARTMENT OF EDUCATION-PAMBUJAN REGULAR/PER
1/1/2007 1/5/2008 SECONDARY SCHOOL TEACHER I 10933.00 11 Y
NATIONAL HIGH SCHOOL MANENT
DEPARTMENT OF EDUCATION-PAMBUJAN REGULAR/PER
1/6/2005 6/30/2007 SECONDARY SCHOOL TEACHER I 9939.00 11 Y
NATIONAL HIGH SCHOOL MANENT

(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
INCLUSIVE DATES
29. NAME & ADDRESS OF ORGANIZATION
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

NONE NONE

(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
DEPARTMENT OF EDUCATION-PAMBUJAN
THREE-DAY SCHOOL-BASED ACTION RESEARCH WRITESHOP 4/1/2017 6/1/2017 24 hrs. TECHNICAL
NATIONAL HIGH SCHOOL
DEPARTMENT OF EDUCATION-PAMBUJAN
3 DAY SEMINAR ON ICT IN TEACHING 12/1/2016 12/3/2016 24 hrs. TECHNICAL
NATIONAL HIGH SCHOOL
DEPARTMENT OF EDUCATION-PAMBUJAN
INTERNATIONAL SEMINAR ON INSTRUCTIONAL LEADERSHIP 3/11/2016 3/13/2016 24hrs. TECHNICAL
NATIONAL HIGH SCHOOL
DIVISION TRAINING OF TRAINERS ON ENHANCING ORAL AND WRITTEN DEPARTMENT OF EDUCATION-PAMBUJAN
12/3/2012 12/5/2012 24 hrs. TECHNICAL
COMMUNICATION SKILLS IN ENGLISH NATIONAL HIGH SCHOOL

(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
(Write in full)
in full)

ENCODING NONE NONE

(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?
✘ NO
YES
✘ NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES
If YES, give details:
________________________________
✘ NO
35. a. Have you ever been found guilty of any administrative offense? YES
If YES, give details:
________________________________
✘ NO
YES ________________________________
b. Have you been criminally charged before any court?
If YES, give details:
________________________________
Date Filed:
NO
________________________________
✘
YES 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,
NOgive details:
YES
________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation, ✘ NO
YES
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? ________________________________
✘ NO
YES ________________________________
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:
NO
YES
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, NO
give details (country):
YES
✘ NO
40. YES
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: ✘ NO
YES
a. 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)

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
JOHN L. DELORINO UEP, Catarman NORTHERN SAMAR 3.5 cm. X 4.5 cm
(passport size)

NOE M. HERMOSILLA PAMBUJAN NORTHERN SAMAR With full and handwritten

name tag and signature over
printed name
JULITO LAGRIMAS PAMBUJAN NORTHERN SAMAR
Computer generated
or photocopied picture
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete is not acceptable
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 administrative/criminal case/s PHOTO
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

ID/License/Passport No.: O814599
Signature (Sign inside the box)
Date/Place of Issuance: 07/18/2003 02/03/2020
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