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 CALIMOTAN

FIRST NAME YSCZYL GRACE NAME EXTENSION (JR., SR)

MIDDLE NAME ROMBLON

3. DATE OF BIRTH 11/23/1992 16. CITIZENSHIP Dual
(mm/dd/yyyy) ✘ Filipino by
Citizenship by
birth
naturalization
4. PLACE OF BIRTH MASBATE,MASBATE If holder of dual citizenship, Pls. indicate country:

5. SEX Male ✘ please indicate the details.

Female
6 CIVIL STATUS ✘ Single Marrie 17. RESIDENTIAL ADDRESS 33 PC CAMP SITE
Widow Separa House/Block/Lot No. Street
d BARANGAY IBINGAY
Other/s
ed ted
Subdivision/Village Barangay
:
MASBATE CITY MASBATE
7. HEIGHT (m) 146 CM
City/Municipality Province
8. WEIGHT (kg) 50 KG ZIP CODE 5400

9. BLOOD TYPE AB 18. PERMANENT ADDRESS 08 MIRASOL ST.

House/Block/Lot No. Street
10.GSIS ID NO. 021-1519-1691-6 BARANGAY BAGUMBAYAN
Subdivision/Village Barangay
MASBATE CITY MASBATE
11.PAG-IBIG ID NO.
City/Municipality Province
12. PHILHEALTH NO. ZIP CODE 5400

13. SSS NO. 19. TELEPHONE NO. NONE

14. TIN NO. 471-907-631-000 20. MOBILE NO. 09196772444

15. AGENCY EMPLOYEE NO. 5819102 21. E-MAIL ADDRESS (if any) ysczylgrace.calimotan@deped.gov.ph

II. FAMILY BACKGROUND

23. NAME of CHILDREN (Write full name and

22.SPOUSE'S SURNAME DATE OF BIRTH (mm/dd/yyyy)
list all)
NAME EXTENSION (JR., SR) N/A
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24.FATHER'S SURNAME CALIMOTAN

NAME EXTENSION (JR., SR) N/A
FIRST NAME JENNY

MIDDLE NAME PRETESTA

25.MOTHER'S MAIDEN NAME NORA MURO ROMBLON

SURNAME ROMBLON

FIRST NAME NORA

MIDDLE NAME MURO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST
LEVEL/
26. NAME OF SCHOOL PERIOD OF ATTENDANCE YEAR SCHOLARSHIP/
BASIC EDUCATION/DEGREE/COURSE UNITS
LEVEL GRADUA ACADEMIC HONORS
(Write in full) EARNED
(Write in full) TED RECEIVED
From To (if not
graduated)
ELEMENTARY BAGUMBAYAN ELEMENTARY SCHOOL ELEMENTARY 1999 2005 GRADUATE 2005 1ST HONOR

MASBATE NATIONAL COMPREHENSIVE

SECONDARY HIGH SCHOOL
HIGH SCHOOL 2005 2009 GRADUATE 2009 9TH HON.MENTION
VOCATIONAL /

TRADE COURSE BACHELOR OF ELEMENTARY EDUCATION

COLLEGE OSMEÑA COLLEGES
(BEED)
2009 2013 GRADUATE 2013 CUMLAUDE

GRADUATE STUDIES OSMEÑA COLLEGES MASTER OF ARTS IN EDUCATION 2014 2017 GRADUATE 2017

(Continue on separate sheet if necessary)

SIGNATURE DATE DECEMBER 15,2020
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) LICENSE (if applicable)
DATE OF
UNDER SPECIAL LAWS/ CES/ CSEE RATING
EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY (If Applicable) NUMBER Date of
CONFERMENT
ELIGIBILITY / DRIVER'S LICENSE Validity
CSE PROFESSIONAL 80.6 MAY 22, 2011 LEGASPI CITY

LET 83.4 JANUARY 26,2014 LEGASPI CITY 1299007

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE
SALARY/
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experience sheet.
JOB/ PAY GOV'T SERVICE
DEPARTMENT / AGENCY / OFFICE / GRADE (if
28. INCLUSIVE DATES POSITION TITLE STATUS OF
(mm/dd/yyyy) COMPANY MONTHLY applicable)
& STEP APPOINTME
(Write in full/Do not SALARY (Format NT
From To (Write in full/Do not abbreviate)
abbreviate) "00-0")/
INCREME (Y/ N)
NT
JULY 1,2020 PRESENT TEACHER 1 DEPED-/ SDO MASBATE CITY 22 600 SG-11 PERMANENT Y

(Continue on separate sheet if necessary)

SIGNATURE DATE DECEMBER 15, 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
NAME & ADDRESS OF ORGANIZATION
29. NUMBER
(Write in full) POSITION / NATURE OF WORK
OF HOURS
From (mm/dd/yyyy)
To
Y-PEER PILIPINAS 2017 PRESENT TREASURER

(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
INCLUSIVE taken for the
DATES OFlast five (5) years for Division Chief/Executive/Managerial positions)
ATTENDANCE Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT
NUMBER ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS (Write in
OF HOURS Supervisory/ (Write in full)
full) (mm/dd/yyyy)To
From Technical/etc)
Division Webinar on Re-Orientation of IPCRF Data Collection System for SY
07/27/20 07/27/20 8 Online SDO-Masbate City
2019-2020

5-Day Capacity Building Webinars for SDO Masbate City on the Most 1/7/2020 7/7/2020 20 Online SDO-Masbate City
Essential Computer Application and Online Platforms

Division Webinar on Learning Delivery Modalities (BATCH 2) 07/29/20 07/29/20 4 Online SDO-Masbate City

Webinar Training About Autodesk and Adobe Photoshop for Beginners 05/13/20 05/15/20 12 Online DEPED-National

Webinar Training About the Use & Curation of Open OER (Basic Program) 05/13/20 05/15/20 12 Online DEPED-Region V

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMBERSHIP IN ASSOCIATION/ORGANIZATION

31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full) (Write in full)

(Continue on separate sheet if necessary)

SIGNATURE DATE DECEMBER 15, 2020

CS FORM 212 (Revised 2017), Page 3 of 4
34. Are you related by consanguinity or affinity to the appointing or recommending
chief of bureau
authority, or office or to the person who has immediate supervision over
or to the
Bureau
you or Office,
in the Department where you will be apppointed,
YES ✘ NO
a. within the third degree?
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: ________________________________
StatusDate
________________________________ Filed:
of Case/s:
36. Have you ever been convicted of any crime or violation of any law, decree, YES ✘ NO
ordinance or regulation by any court or tribunal? If YES, give details: ________________________________
________________________________
YES ✘ NO
37. Have you ever been separated from the service in any of the following modes:
resignation, retirement, dropped from the rolls, dismissal, termination, end of If YES, give details: ________________________________
YES NO
term, finished contract or 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 (except Barangay election)? YES If YES,NO
✘
give details:
b. Have you resigned from the government service during the three (3)-month
period before the last election to promote/actively campaign for a national or YES ✘ NO
If YES, give details:
local
Havecandidate?
you acquired the status of an immigrant or permanent resident of
39.
another country? If YES, give details (country):

40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for YES ✘ NO
Disabled Persons (RA 7277); and (c) Solo Parents Welfare Act of 2000 (RA
YES NO
a 8972),
Are youplease answer the following items: ✘
a member of any indigenous group?
. 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?
. If YES, please specify ID No:

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAME ADDRESS CONTACT NO. ID picture taken within
the last 6 months
OSMEÑA ST. MASBATE 3.5 cm. X 4.5 cm
DELIA FLORESTA VALENCIA CITY 9468224059 (passport size)

With full and handwritten

PC CAMP SITE name tag and signature over
RUFINO BALACE ARELLANO 9097578752 printed name
MASBATE CITY
Computer generated
or photocopied picture
NURSERY ST.MASBATE
JONALD BLACER SIA 9102624511 is not acceptable
CITY
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and
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 IssuedPRC -ID

ID/License/Passpor1299007
Signature (Sign inside the box)
DECEMBER 15, 2020
Date/Place of Issu APRIL 2014/ LEGASPI CITY Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.

Administering Oath

CS FORM 212 (Revised 2017), Page 4 of 4