CS Form No.

212

PERSONAL DATA SHEET

Revised 2017

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 ACCOM PLISHING 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 AB ON
N A M E E XTE N S IO N (J R ., S R )
FIRST NAME DON AL YN N/A

MIDDLE NAME VERUEL A

3. DATE OF BIRTH
(mm/dd/y y y y )
4. PLACE OF BIRTH
5. SEX
JANUARY 8,1991 16. CITIZENSHIP
Filipino Dual Citizenship
by birth by naturalization
CUYAPO, NUEVA ECIJA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
Male Female

Single Married 17. RESIDENTIAL ADDRESS N/A PUROK 5

6 CIVIL STATUS
Widowed House/Block/Lot No. Street
Separated
N/A SALAGUSOG
Other/s:
Subdivision/Village Barangay
CUYA PO NUEVA ECIJA
7. HEIGHT (m) 1.52
City/Municipality Province
8. WEIGHT (kg) 50 ZIP CODE 3117
18. PERMANENT ADDRESS N/A PUROK 5
9. BLOOD TYPE AB
House/Block/Lot No. Street
N/A SALAGUSOG
10. GSIS ID NO. N/A
Subdivision/Village Barangay
CUYA PO NUEVA ECIJA
11. PAG-IBIG ID NO. 121029882578
City/Municipality Province
12. PHILHEALTH NO. 21-050048348-7 ZIP CODE 3117

13. SSS NO. 34-1455371-3 19. TELEPHONE NO. N/A

14. TIN NO. 736 826 134 000 20. MOBILE NO. 09272354010
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any ) DonalynJeff.0806vi@gmail.com
II. FAMILY BACKGROUND
DATE OF BIRTH
22. SPOUSE'S SURNAME ABON 23. NAME of CHILDREN (Write full name and list all)
(mm/dd/y y y y )
N A M E E XTE N S IO N N/A
FIRST NAME GILBERT ( J R ., S R ) N / A
06/06/1990

MIDDLE NAME IMUS

OCCUPATION VENDOR

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS CUYAPO, NUEVA ECIJA

TELEPHONE NO. 9957865304

24. FATHER'S SURNAME VERUELA 12/18/1958

N A M E E XTE N S IO N
FIRST NAME DOMINADOR ( J R ., S R ) S R

MIDDLE NAME MINOR

25. MOTHER'S MAIDEN NAME CASIDSID 08/06/1968

SURNAME VERUELA

FIRST NAME LIDA

MIDDLE NAME REBOSTE (Con tinu e on sep arate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHES T
S C HOLAR S HIP /
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE P ERIOD OF ATTENDANC E LEVEL/ YEAR
ACADEM IC
LEVEL UNITS GR ADU
(Write in full) (Write in full) EARNED ATED
HONORS
From To R ECEIVED
(if no t

ELEMENTARY SA BIT EL EMENTARY SCHOOL ELEMENTARY 1999 2003 GRADUA TED 2003 THIRD HONOR

SECONDARY SA LAGUSOG NA TIONAL HIGH SCHOOL SECONDARY 2003 2007 GRADUA TED 2007 WITH HONOR
VOCATIONAL /
N/A N/A N/A N/A N/A N/A N/A
TRADE COURSE
BACHELOR OF SECONDA RY EDUCATION-
COLLEGE URDANETA CITY UNIVERSITY 2015 2018 GRADUA TED 2018 N.E SCHOLAR
MAJOR IN GENERA L SCIENCE

GRADUATE STUDIES COLEGIO DE DAGUPA N MED-GENERA L SCIENCE 2018 PRESENT 36 UNITS N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE MARCH 25,2021

CS FOR M 212 (R e v is e d 2017), P age 1 o f 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER RATING DATE OF LICENSE (if applicable)
SPECIAL LAWS/ CES/ CSEE (If EXAMINATION / PLACE OF EXAMINATION / CONFERMENT Date of
NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE Applicable) CONFERMENT Validity

LICENSURE EXAMINATION FOR TEACHERS 77.4 09/30/2018 ROSALES NATIONAL HIGH SCHOOL 1739281 01/08/2022

(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.
28. INCLUSIVE DATES SALARY/ JOB/

(mm/dd/y y y y ) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY

PAY GRADE (if
STATUS OF GOV'T SER VICE
ap p licab le)& STEP
(Write in full/Do not abbrev iate) (Write in full/Do not abbrev iate) SALARY (Fo rmat "0 0-0")/
AP P OINTMENT (Y/ N)
From To INCREMENT

10/05/2020 PRESENT MLSB-TEACHER VILLAFLORES INTEGRATED SCHOOL 4000.00 N/A PROBATIONARY N/A

06/03/2019 12/13/2019 MLSB-TEACHER VILLAFLORES INTEGRATED SCHOOL 4000.00 N/A PROBATIONARY N/A

01/16/2019 04/15/2019 DAYCARE WORKER SALAGUSOG DAY CARE CENTER 6000.00 N/A PROBATIONARY N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE MARCH 25,2021

CS FOR M 212 (R evis ed 2017), P age 2 o f 4
 VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
29. NUMBER
NAME & ADDRESS OF ORGANIZATION (Write in full) (mm/dd/yy y y ) POSITION / NATURE OF WORK
OF HOURS
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 m ost 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 Type o f LD
30. NUMBER ( Ma nagerial/ CONDUCTED/ SPONSORED BY
TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS (Write in full) ATTENDANCE OF HOURS Supervis o ry/ (Write in full)
From To Technica l/etc)

DIGITAL POETRY: A COLLABORATIVE PERFORMANCE PROJECT 03/19/2021 03/19/2021 90m ins. SUPERVISORY DepEd Philippines
CREATING INTERACTIVE MATERIALS USING SCRATCH ANIMATION 03/19/2021 03/19/2021 90m ins. SUPERVISORY DepEd Philippines
MOBILE APPS IN EDUCATION 03/18/2021 03/18/2021 90m ins. SUPERVISORY DepEd Philippines
ETUlay-BREAKTHROUGH IN TEACHING 03/18/2021 03/18/2021 90m ins. SUPERVISORY DepEd Philippines

OVERVIEW OF R.A. 10173, THE DATA PRIVACY ACT OF 2012 03/17/2021 03/17/2021 90m ins. SUPERVISORY DepEd Philippines

GOOGLE WORKSPACE FOR EDUCATION FUNDAMENTALS 03/17/2021 03/17/2021 90m ins. SUPERVISORY DepEd Philippines

OER READINESS REVIEW CRITERIA 03/16/2021 03/16/2021 90m ins. SUPERVISORY DepEd Philippines

EFFECTIVE UTILIZATION OF MULTIMEDIA MATERIALS:DepEd TV 03/16/2021 03/16/2021 90m ins. SUPERVISORY DepEd Philippines

A NEW NORMAL:THE CRITICAL ROLE ASSESSMENT IN ONLINE LEARNING 03/16/2021 03/16/2021 90m ins. SUPERVISORY DepEd Philippines

EFFECTIVE DELIVERY OF SYNCHRONOUS/ASYNCHRONOUS TEACHING 03/15/2021 03/15/2021 3.0 SUPERVISORY DepEd Philippines

HILOT WELLNESS MASSAGE 11/11/2019 29/11/2019 191.0 TECHNICAL TESDA

COMPUTER LITERACY PROGRAM 02/08/2019 4/24/2019 191.0 TECHNICAL TESDA
6TH NATIONAL SEMINAR WORKSHOP ON MANIPULATIVE LABORATORY SKILLS FOCUSED ON EXPERIMENTAL AND
08/05/2019 10/05/2019 30.0 SUPERVISORY ASIAN FISHERIES ACADEMY
DESCRIPTIVE RESEARCHES
SCHOOL BASED IN SERVICE TRAINING OF TEACHERS ON WRITING AND DEVELOPING CONTEXTUALIZED STRATEGIC SAN LUIS NATIONAL HIGH
5/15/2019 5/17/2019 8.0 SUPERVISORY
INTERVENTION(SIM) K TO 12 CURRICULUM SCHOOL
SAN LUIS NATIONAL HIGH
MUNICIPAL TRAINING WORKSHOP ON DEVELOPMENT OF QUALITY CLASSROOM BASED TEST FOR TEACHERS 7/13/2019 7/27/2019 8.0 SUPERVISORY
SCHOOL
ORIENTATION SEMINAR ON THE NEW EARLY CHILDHOOD CARE AND DEVELOPMENT PROGRAM ACCREDITATION PROVINCIAL SOCIAL WELFARE
3/17/2019 3/19/2019 30.0 SUPERVISORY
TOOLS CUM GAME BASED LEARNING AND DEVELOPMENT OFFICE
(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. ASSOCIATION/ORGANIZATION
(Write in full)
(Write in full)
MASSAGE THERAPIST N/A N/A

COMPUTER LITERATE

DRIVING MOTORCYCLE

COOKING

WATCHING MOVIES

READING BOOKS

(Continue on separate sheet if necessary)

SIGNATURE DATE MARCH 25,2021

CS FOR M 212 (R evis ed 2017), P age 3 o f 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
Datedetails:
________________________________
Filed:
Status of Case/s:
36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by
YES NO
any court or tribunal?
If YES, give details:
________________________________

37. Have you ever been separated from the service in any of the following modes: resignation, retirement,
YES NO
dropped from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in If YES, give details:
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
JEANE A FELIX 9162428375 the last 6 months
VILLAFLORES, CUYAPO, NUEVA ECIJA 3.5 cm. X 4.5 cm
(passport size)
DIGNA B. PASCUAL SALAGUSOG, CUYAPO, NUEVA ECIJA 9052756397
With f ull and handwritten
CLARISSA A. CAYTON SALAGUSOG, CUYAPO, NUEVA ECIJA 9167534809 name tag and signature ov er
printed name
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete statement
Computer generated
pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. I authorize the agency or photocopied picture
is not acceptable
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 against me. PHOTO

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 LICENSE

ID/License/Passport No.: 1739281 Signature (Sign inside the box)
MARCH 25,2021
Date/Place of Issuance: 1/23/2019/ ROSALES PANGASINAN
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

C S FOR M 212 (R e v is e d 2017), P age 4 o f 4