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 BALLESTEROS
NAME EXTENSION (JR., SR)
FIRST NAME GRETCHEN
MIDDLE NAME RAMIREZ
3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
3/4/1994 by
by naturalization
birth
4. PLACE OF BIRTH LANDINGAN, NAGTIPUNAN, QUIRINO 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 House/Block/Lot No. Street

Separate
Other/s: d PONGGO
Subdivision/Village Barangay
7. HEIGHT (m) 1.48 NAGTIPUNAN QUIRINO
City/Municipality Province
8. WEIGHT (kg) 46.5 ZIP CODE 3405
18. PERMANENT ADDRESS
9. BLOOD TYPE O+
House/Block/Lot No. Street

10. GSIS ID NO. N/A PONGGO

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1211-5734-8654 NAGTIPUNAN QUIRINO

City/Municipality Province

12. PHILHEALTH NO. 06-000082489-8 ZIP CODE 3405

13. SSS NO. N/A 19. TELEPHONE NO. N/A
14. TIN NO. 474-555-270 20. MOBILE NO. 09657595890
15. AGENCY EMPLOYEE NO. (078) 692-5019 21. E-MAIL ADDRESS (if any) gretchen.ballesteros003@deped.gov.ph
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME N/A N/A N/A
MIDDLE NAME N/A
OCCUPATION N/A
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME BALLESTEROS
NAME EXTENSION (JR., SR)
FIRST NAME VIC
MIDDLE NAME CUMLAT
25. MOTHER'S MAIDEN NAME

SURNAME RAMIREZ
FIRST NAME EDITHA
MIDDLE NAME OCAMPO (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

ELEMENTARY NAGTIPUNAN CENTRAL SCHOOL ELEMENTARY 2001 2006 GRADUATED 2006 9th
NAGTIPUNAN NATIONAL HIGH
SECONDARY /
VOCATIONAL SECONDARY 2006 2010 GRADUATED 2010 8th
SCHOOL
ISABELA STATE UNIVERSITY-
FOOD PROCESSING NC II 2014 2015 COMPLETED 2015 N/A
TESDA
TRADE
BACHELOR IN ELEMENTARY
COURSE
COLLEGE ISABELA STATE UNIVERSITY 2010 2014 GRADUATED 2014 N/A
EDUCATION
MASTER OF ARTS IN
GRADUATE STUDIES NORTHEASTERN COLLEGE 2015 2016 GRADUATED 2019 N/A
EDUCATION
(Continue on separate sheet if necessary)

SIGNATURE DATE July 16, 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 80.6% 8/14/2014 TUGUEGARAO CITY 1314390 3/4/2023

(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/ 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)

6/1/2015 8/31/2015 CASECNAN FUND TEACHER DEPARTMENT OF EDUCATION Php 7,000.00 N/A CASUAL Y

9/1/2015 PRESENT TEACHER-I DEPARTMENT OF EDUCATION Php 22, 600 11-2 PERMANENT Y

(Continue on separate sheet if necessary)

SIGNATURE DATE 07/16/20

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

Division Training on Values Formation and Work Ethics 11/26/201511/28-28/2015 24 TECHNICAL DEPARTMENT OF EDUCATION
Basic Training Course for Troop Leaders/ Outfit Advisors 11/10/2016 11/12/2016 24 TECHNICAL DEPARTMENT OF EDUCATION

Learning and Development Orientation- Training Workshop for Multigrade Teachers 11/21-25/201612/1-3,5-6/2016 80 TECHNICAL DEPARTMENT OF EDUCATION

Learning and Development Activity of Untrained Kindergarten Teachers 12/12/2016 12/14/2016 24 TECHNICAL DEPARTMENT OF EDUCATION
Division Literacy and Numeracy Enhancement Training and Workshop for Multigrade 12/22-23/2015
01/20-22/2016 40 TECHNICAL DEPARTMENT OF EDUCATION
ORIENTATION WORKSHOP ON THE HARMONIZATION OF UNDERSTANDING OF K
TO 12 CLASSROOM ASSESSMENT AND AWARDS AND RECOGNITION
3/11/2017 3/11/2017 8 TECHNICAL DEPARTMENT OF EDUCATION
ORIENTATION WORKSHOP ON NUTRITIONAL ASSESSMENT 6/23/2017 6/23/2017 8 TECHNICAL DEPARTMENT OF EDUCATION
TRAINING WORKSHOP ON THE ENHANCEMENT OF PHYSICAL FITNESS TEST
AND PROPER INTERPRETATION OF DATA
11/30/2017 12/2/2017 24 TECHNICAL DEPARTMENT OF EDUCATION
LEARNING AND DEVELOPMENT ON FINANCIAL MANAGEMENT OPERATIONS
MANUAL (FMOM)
12/6/2017 12/8/2017 24 TECHNICAL DEPARTMENT OF EDUCATION
CAPACITY BUILDING FOR LIS/ EBEIS COORDINATORS 2/26/2018 2/26/2018 8 TECHNICAL DEPARTMENT OF EDUCATION
DISTRICT TRAINING ON THE RESULT-BASED PERFORMANCE MANAGEMENT
SYSTEM (RPMS) MANUAL FOR TEACHERS AND SCHOOL HEADS
7/11/2018 7/13/2018 24 TECHNICAL DEPARTMENT OF EDUCATION
TINTALAS(SHARPENING OF THE PEN): GEARING UP ON QUALITY CAMPUS
JOURNALISM FOR SCHOOL PAPER ADVISERS
9/20/2018 9/22/2018 24 TECHNICAL DEPARTMENT OF EDUCATION
INTERNATIONAL TRAINING/ SEMINAR/ WORKSHOP ON LEADERSHIP AND
MANAGEMENT
2/8/2019 2/10/2019 24 TECHNICAL DEPARTMENT OF EDUCATION

(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)
QUIRINO PUBLIC SCHOOL TEACHERS,
READING BOOKS N/A
EMPLOYEES, RETIREES ASSOCIATION
NAGTIPUNAN PUBLIC SCHOOL TEACHERS,
INTERNET SURFING
EMPLOYEES, RETIREES ASSOCIATION

(Continue on separate sheet if necessary)

SIGNATURE DATE JULY 16, 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 ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘

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
IRENE D. CORPUZ PONGGO, NAGTIPUNAN, QUIRINO N/A 3.5 cm. X 4.5 cm
(passport size)

LUCIA R. CORPUZ PONGGO, NAGTIPUNAN, QUIRINO N/A With full and handwritten
name tag and signature over
printed name
JONATHAN F. MAURICIO PONGGO, NAGTIPUNAN, QUIRINO N/A
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: PRC ID

ID/License/Passport No.: 1314390

Signature (Sign inside the box)
JULY 16, 2020
Date/Place of Issuance: 11/11/14- 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