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 ABLOG
NAME EXTENSION (JR., SR) N/A
FIRST NAME MARY ANN

MIDDLE NAME RAMIREZ

3. DATE OF BIRTH
06/29/1989 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH LA SUERTE, AMULUNG,CAGAYAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female
17. RESIDENTIAL ADDRESS N/A N/A
6 CIVIL STATUS Single ✘ Married
House/Block/Lot No. Street
Widowed Separate
ZONE 5 LA SUERTE
Other/s: d Subdivision/Village Barangay
7. HEIGHT (m) 1.48 AMULUNG CAGAYAN
City/Municipality Province
8. WEIGHT (kg) 55 ZIP CODE 3505

18. PERMANENT ADDRESS N/A N/A

9. BLOOD TYPE B
House/Block/Lot No. Street

10. GSIS ID NO. 2005032722

N/A LA SUERTE
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1210-7053-0409 AMULUNG CAGAYAN

City/Municipality Province

12. PHILHEALTH NO. 06-050110518-2 ZIP CODE 3505

13. SSS NO. 01-2018211-2 19. TELEPHONE NO. N/A

14. TIN NO. 404-470-624 20. MOBILE NO. 09970738330

15. AGENCY EMPLOYEE NO. 5346872 21. E-MAIL ADDRESS (if any) marryann.ablog@deped.gov.ph
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME ABLOG 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

ABLOG, ROANNE DOMINIQUE RAMIREZ

FIRST NAME RONALD 8/14/2015

MIDDLE NAME IRECE ABLOG, RONA MARY DOMINIQUE RAMIREZ 10/8/2019

OCCUPATION SEAMAN

EMPLOYER/BUSINESS NAME MAGSAYSAY MARITIME COMPANY

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME RAMIREZ

FIRST NAME ANTONIO

MIDDLE NAME GAMBOL

25. MOTHER'S MAIDEN NAME

SURNAME TAGACAY

FIRST NAME MINA

MIDDLE NAME EYA (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

ELEMENTARY LA SUERTE ELEMENTARY SCHOOL PRIMARY EDUCATION 1996 2002 N/A 2002 N/A

SECONDARY /
VOCATIONAL CAGAYAN NATIONAL HIGH SCHOOL HIGH SCHOOL 2002 2006 N/A 2006 N/A

N/A N/A N/A N/A N/A N/A N/A

TRADE
COURSE BACHELOR IN SECONDARY EDUCATION MAJOR
COLLEGE UNIVERSITY OF SAINT LOUIS
IN BIOLOGIAL SCIENCE
2006 2010 N/A 2010 N/A

GRADUATE STUDIES UNIVERSITY OF SAINT LOUIS MASTERS IN SCIENCE TEACHING 2011 2012 15 UNITS N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE CS FORM 212 (Revised 2017), Page 1 of 4

 P
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER LICENSE (if applicable)
RATING
SPECIAL LAWS/ CES/ CSEE PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE
Validity

LICENSURE EXAMINATION FOR TEACHERS 75.02 TUGUEGARAO CITY, CAGAYAN 1110078 6/29/2022

(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 DEPARTMENT / AGENCY / OFFICE / SALARY/ JOB/ PAY SERVICE
POSITION TITLE GRADE (if
(mm/dd/yyyy) COMPANY MONTHLY STATUS OF
(Write in full/Do not SALARY
applicable)& STEP
APPOINTMENT
(Write in (Format "00-0")/
abbreviate)
From To full/Do not abbreviate) INCREMENT
(Y/ N)
BAYABAT NATIONAL HIGH SCHOOL-
01/01/2021 PRESENT TEACHER II ₱ 26,052.00 SG12 PERMANENT YES
LA SUERTE EXTENSION
BAYABAT NATIONAL HIGH SCHOOL-
1/1/2020 12/31/2020 TEACHER II ₱ 24,495.00 SG12 PERMANENT YES
LA SUERTE EXTENSION
BAYABAT NATIONAL HIGH SCHOOL-
1/1/2019 12/31/2019 TEACHER II ₱ 22,149.00 SG12 PERMANENT YES
LA SUERTE EXTENSION
BAYABAT NATIONAL HIGH SCHOOL-
06/21/2018 12/31/2018 TEACHER II ₱ 22,149.00 SG12 PERMANENT YES
LA SUERTE EXTENSION
BAYABAT NATIONAL HIGH SCHOOL-
6/20/2016 6/20/2018 TEACHER I ₱ 21,620.00 SG11 PERMANENT YES
LA SUERTE EXTENSION

6/6/2010 3/31/2014 TEACHER LYCEUM OF APARRI ₱ 8,000.00 N/A CONTRACTUAL NO

(Continue on separate sheet if necessary)

SIGNATURE 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

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
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

DISTRICT IN- SERVICE TRAINING 02/08/21 02/13/21 48 TECHNICAL DISTRICT

10/21/2019 10/25/2019 40 TECHNICAL

DISTRICT IN- SERVICE TRAINING DISTRICT

07/06/2018 07/07/2018 16 TECHNICAL

AMULUNG WEST DISTRICT ROLL-OUT SEMINARWORKSHOP ON THE RPMS DISTRICT

10/22,2018 10/26/2018 40 TECHNICAL

IN- SERVICE TRAINING DEPARTMENT OF EDUCATION-CAGAYAN
BAYABAT NATIONAL HIGH SCHOOL-LA SUERTE
IN- SERVICE TRAINING 10/23/217 10/27/2017 40 TECHNICAL
EXTENSION

MASS TRAINING OF GRADE 12 SHS TEACHERS ON COMMON TOPICS 05/22/2017 05/25/2017 32 TECHNICAL DEPARTMENT OF EDUCATION REGION 02

SHS MASS TRAINING OF GRADE 12 TEACHERS ON ACADEMIC 05/27/2017 1/6/2017 48 TECHNICAL DEPARTMENT OF EDUCATION REGION 02
DEPARTMENT OF EDUCATION REGION 02
SHS MASS TRAINING OF GRADE 12 TEACHERS ON ACADEMIC 06/24/2017 06/29/2017 48 TECHNICAL

REGIONAL TRAINING OF TRAINERS AND CAREER ADVOCATES FOR THE DEPARTMENT OF EDUCATION REGION 02
11/20/2017 11/23/2017 24.0 TECHNICAL
IMPLEMANTATION OF THE CAREER GUIDANCE
DEPARTMENT OF EDUCATION REGION 04
IN SERVICE TRAINING 10/23/2017 10/27/2017 40 TECHNICAL

(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)

DANCING N/A N/A

PLAYING BADMINTON N/A N/A

(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 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:
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
MARICEL V. MEDRANO BAYABAT, AMULUNG, CAGAYAN N/A 3.5 cm. X 4.5 cm
(passport size)

GRACE L. TABAOG BAYABAT, AMULUNG, CAGAYAN N/A With full and handwritten
name tag and signature over
printed name
MARCIANO ENRIQUE LA SUERTE, AMULUNG, CAGAYAN N/A
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete or photocopied picture
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/License/Passport No.: 1110078

Signature (Sign inside the box)
02/11/2021
Date/Place of Issuance: TUGUEGARAO 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