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
PALLER
FIRST NAME
SWEET DIANA DAWN
MIDDLE NAME
POTESTAS
3. DATE OF BIRTH
(mm/dd/yyyy) 1/24/1990 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH PAGADIAN CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female
17. RESIDENTIAL ADDRESS 0144
6 CIVIL STATUS Single Married
Widowed House/Block/Lot No. Street
✘ Separated
PUROK MAHOGANY, BUENAVISTA
Other/s:
Subdivision/Village Barangay
PAGADIAN CITY, ZAMBOANGA DEL SUR
7. HEIGHT (m) 1.524
City/Municipality Province
8. WEIGHT (kg) 65 ZIP CODE

18. PERMANENT ADDRESS 0144

9. BLOOD TYPE
House/Block/Lot No. Street
PUROK MAHOGANY, BUENAVISTA
10. GSIS ID NO.
Subdivision/Village Barangay
PAGADIAN CITY, ZAMBOANGA DEL SUR
11. PAG-IBIG ID NO.
City/Municipality Province
12. PHILHEALTH NO. 140501363835 ZIP CODE 7016

13. SSS NO. 1008317503000 19. TELEPHONE NO. N/A

14. TIN NO. 405111371 20. MOBILE NO. 09166203444

15. AGENCY EMPLOYEE NO.
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME
FIRST NAME
N/A 21. E-MAIL ADDRESS (if any) sweetpaller04@gmail.com
23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME DECEASED

NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

25. MOTHER'S MAIDEN NAME

SURNAME POTESTAS

FIRST NAME MARYSOL

MIDDLE NAME CARACUT (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

VALEDICTORIA
ELEMENTARY BUENAVISTA ELEMENTARY SCHOOL 1995 2000 2000 N

WITH
SECONDARY ZSNHS-STA. LUCIA ANNEX 2001 2004 2004
HONORS
BACHELOR ON ELEMENTARY
COLLEGE WESTERN MINDANAO STATE UNIVERSITY 2005 2009 20009 CUM LAUDE
EDUCATION
MASTER OF ARTS IN EDUCATION MAJOR IN
SAINT COLUMBAN COLLEGES ENGLISH
2011 7/5/1905 2013
GRADUATE STUDIES

SECOND COURSE JH Cerilles State College BACHELOR OF LAWS 2019 TO PRESENT

(Continue on separate sheet if necessary)

SIGNATURE DATE August 19, 2020

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 79.40% 10/1/2009 PAGADIAN 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/ 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)

AUG. 2009 AUG. 2010 WEBSITE WRITER TEAM LEADER FIRSTPAGE WEBSEARCH SOLUTIONS 8,000.00 N/A PERMANENT N

JAN. 2011 JAN. 2017 ELEMENTARY SCHOOL TEACH - III DEPARTMENT OF EDUCATION - PAGADIAN CITY 18,000.00 N/A PERMANENT Y

JAN. 2018 Jun-19 BUSINESS UNIT MANAGER MANULIFE PHILIPPINES 20,000.00 N/A CONTRACTUAL N

JAN. 2020 AUG. 2020 LEGAL ADMINISTRATIVE STAFF PADAYHAG LAW OFFICE 6,000.00 N/A TEMPORARY N

(Continue on separate sheet if necessary)

SIGNATURE DATE AUGUST 19, 2020

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

LEADERSHIP TRAINING 06/16/2016 06/16/2016 8 FRANCIS KONG

LEADERSHIP TRAINING 6/20/2016 6/20/2016 4

CHINKEE TAN

LEADERS DEVELOPMENT PROGRAM (ASPIRE TRACK) 6/19/2018 6/21/2018 24

MANULIFE PHILIPPINES

LEADERS FOR RESULTS TRAINING WORKSHOP 12/10/2018 12/13/2018 32

MANULIFE PHILIPPINES

(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 in
(Write in full)
full)

CONTENT WRITING N/A N/A

WEBSITE OPTIMIZATION

TEACHING

(Continue on separate sheet if necessary)

SIGNATURE DATE AUGUST 19, 2020

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
out (abolition) in the public or private sector? If YES, give details:
________________________________
________________________________

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
ATTY. MARY JOAN B. SARMIENTO PAGADIAN CITY 9399380989 3.5 cm. X 4.5 cm
(passport size)

ENGR. BENJAMIN D. MACAUMBANG, JR. PAGADIAN CITY 9092131954 With full and handwritten
name tag and signature over
printed name
ATTY. RODOLPH JOHN DELA CRUZ PAGADIAN CITY 9162400972
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: DRIVER'S LICENSE

ID/License/Passport No.: J03-12-001356

Signature (Sign inside the box)

Date/Place of Issuance: PAGADIAN CITY

AUGUST 19, 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

 PROFESSIONAL EXPERIENCE SHEET
Attachment to CS Form No. 212

Instructions: The duration should include start and finish dates, if known, month in abbreviated form known and year in full. For
the current position, use the word Present, e.g. 1998 - Present. Professional experience should be listed from most recent first.

• Duration (Inclusive Dates)

• Position, Name of Office/Unit and Immediate Supervisor, Name of Agency/Organization and Location

> List of Accomplishments and Contributions (if any)

> Description of Duties

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( Signature over Printed Name of Employee/Applicant)

Date: ______________________