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 AMPONG
NAME EXTENSION (JR., SR)
FIRST NAME ADRIAN FRED

MIDDLE NAME BALONDO

3. DATE OF BIRTH
(mm/dd/yyyy) 05 26 1999 16. CITIZENSHIP ✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH MASAGONGSONG, KAWAYAN, BILIRAN 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
N/A MASAGONGSONG
Other/s:
Subdivision/Village Barangay
KAWAYAN BILIRAN
7. HEIGHT (m) 1.72
City/Municipality Province
8. WEIGHT (kg) 69 ZIP CODE 6562
18. PERMANENT ADDRESS
9. BLOOD TYPE O
House/Block/Lot No. Street
N/A MASAGONGSONG
10. GSIS ID NO. N/A
Subdivision/Village Barangay
KAWAYAN BILIRAN
11. PAG-IBIG ID NO. N/A
City/Municipality Province
12. PHILHEALTH NO. N/A ZIP CODE 6562

13. SSS NO. N/A 19. TELEPHONE NO.

14. TIN NO. N/A 20. MOBILE NO. 09159644257

15. AGENCY EMPLOYEE NO.
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME
FIRST NAME
N/A 21. E-MAIL ADDRESS (if any) fredbalondo26@@gmail.com
N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) N/A
N/A

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME AMPONG

JR.
FIRST NAME ADRIANO

MIDDLE NAME GADITANO

25. MOTHER'S MAIDEN NAME

SURNAME AMPONG

FIRST NAME LEIZL

MIDDLE NAME BALONDO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE UNITS
YEAR
ACADEMIC
LEVEL (Write in full) EARNED
GRADUATED
HONORS
(Write in full) (if not RECEIVED
From To
graduated)
1ST
MASAGONGSONG ELEMENTARY
ELEMENTARY
SCHOOL 2011 HONORABLE
MENTION
VOCATIONAL / 8TH
SECONDARY KAWAYAN NATIONAL HIGH SCHOOL 2015 HONORABLE
MENTION
N/A

COLLEGE TRADE
Proficiency
BILIRAN PROVINCE STATE UNVERSITY BACHELOR OF SECONDARY EDUCATION 2019
COURSE Awardee
GRADUATE STUDIES N/A

(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
SEPTEMBER 29,
LICENSURE EXAMINATION FOR TEACHERS 83.6 2019
TACLOBAN CITY 1838718 05 26 2023

(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 SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To
(Y/ N)
N/A N/A N/A N/A N/A N/A N/A N/A

(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

N/A N/A N/A N/A 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
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) From To Technical/etc)

EXPERENTIAL LEARNING COURSES 7/11/2016 03/15/2019 BILIRAN PROVINCE STATE UNIVERSITY

TECHNICAL EDUCATION AND SKILLS
NC1 ( AGRICULTURAL CROP PRODUCTION) 01/20/2020 01/20/2020 8.0
DEVELOPMENT AUTHORITY
PHILIPPINE ASSOCIATION FOR TEACHERS
ANNUAL REGIONAL TEACHING CONGRESS 02/23/2019 02/23/2019 8.0
AND EDUCATORS
RESEARCH-LYMPICS 2018 10/29/2018 10/31/2018 24.0 NSU-RESEARCH SERVICE OFFICE

1ST AGRIBUSINESS DAY 09/26/2018 09/26/2018 8.0 NSU-RESEARCH SERVICE OFFICE

2ND UNANG HAKBANG NI JUAN: LEADERSHIP
1/8/2018 1/8/2018 8.0 ESTUDIOS SOCIALES SOCIEDAD
TRAINING
INTERCOLLEGIATE FEDERALISM DEBATE- DEPARTMENT OF INTERIOR AND LOCAL
03/22/2018 03/22/2018 8.0
PROVINCIAL GOVERNMENT
NATIONAL FAMILY PLANNING CONFERENCE 8/11/2017 9/11/2017 16.0 DEPARTMENT OF HEALTH
2ND NATIONAL FAMILY PLANNING YOUTH UN- SUSTAINABLE DEVELOPMENT
6/11/2017 7/11/2017 16.0
CONFERENCE SOLUTIONS NETWORK YOUTH
NAST SYMPOSIUM FOR THE YOUTH WITH THE NATIONAL ACADEMY OF SCIENCE AND
10/18/2017 10/18/2017 8.0
NATIONAL SCIENTIST TECHNOLOGY
K+12 CURRICULUM AND LESSON PLANNING
09/27/2017 09/29/2017 24.0 ESTUDIOS SOCIALES SOCIEDAD
SEMINAR-WORKSHOP
SK REFORM LAW SEMINAR 9/9/2016 9/9/2016 8.0 ESTUDIOS SOCIALES SOCIEDAD
NSU-NATIONAL SERVICE TRAINING
LITERACY TRAINING SERVICE 05/16/2015 8/4/2019
PROGRAM

(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)
ESTUDIOS SOCIALES SOCIEDAD-
COMPUTER LITERATE SANGGUNIANG KABATAAN TREASURER
PRESIDENT (2017-2018)
PHOTO EDITING/PHOTOGRAPHY RESEARCH-LYMPICS 2018 PARTICIPANT

READING 1ST AGRIBUSINESS DAY PARTICIPANT

INTERCOLLEGIATE FEDERALISM DEBATE- PROVINCIAL
COOKING
PARTICIPANT
INTERNET SAVANT

(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? ________________________________
________________________________
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 YES ✘ NO
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?
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
a.
items:
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
MASAGONGSONG, KAWAYAN, the last 6 months
VIRGINIA D. AMBE BIL,
9778299635 3.5 cm. X 4.5 cm
(passport size)

GINA B. ANG POBLACION, KAWAYAN,BIL. 9561032662 With full and handwritten

name tag and signature over
printed name
CAROLINA O. AMPONG NAVAL, BILIRAN 9757314818
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 PHOTO
filing of 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.: 1838718

Signature (Sign inside the box)

Date/Place of Issuance: 01/09/2020 / TACLOBAN CITY

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