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 LOZADA
NAME EXTENSION (JR., SR)
FIRST NAME ROSEMARIE

MIDDLE NAME EBALLA

3. DATE OF BIRTH
(mm/dd/yyyy) 05/06/1977 16. CITIZENSHIP ✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH TAGUM If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS PUROK MALIGAYA

Widowed Separated House/Block/Lot No. Street
ROSARIO
Other/s:
Subdivision/Village Barangay
TANDAG SURIGAO DEL SUR
7. HEIGHT (m) 5"1
City/Municipality Province
8. WEIGHT (kg) 65KGS ZIP CODE 8300

18. PERMANENT ADDRESS PUROK MALIGAYA

9. BLOOD TYPE "AB+"
House/Block/Lot No. Street
ROSARIO
10. GSIS ID NO. UMIDNo.006-0075-4339-9
Barangay
TANDAG SURIGAO DEL SUR
11. PAG-IBIG ID NO. 1211-6079-7959
City/Municipality Province

12. PHILHEALTH NO. 180000510953 ZIP CODE 8300

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

14. TIN NO. 280-551-442-000 20. MOBILE NO. 09105806607

15. AGENCY EMPLOYEE NO. 4236819 21. E-MAIL ADDRESS (if any) rosemarie.lozada002@deped.gov.ph
rosemarieeballa557@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME LOZADA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) ADAM BENEDICT E. LOZADA
FIRST NAME MARIETO CLEBEN 2/7/2002

MIDDLE NAME VILLARIASA ROSE THERESE E. LOZADA 12/15/2005

OCCUPATION EPS II CLARE BLESS E. LOZADA 12/16/2008

EMPLOYER/BUSINESS NAME DEPED DIVISION OF SURIGAO DEL SUR

BUSINESS ADDRESS MABUA,BALILAHAN,TANDAG CITY

TELEPHONE NO. 3970

24. FATHER'S SURNAME EBALLA

NAME EXTENSION (JR., SR)
FIRST NAME LEON (DECEASED)

MIDDLE NAME TAJONERA

25. MOTHER'S MAIDEN NAME

SURNAME ELNAR

FIRST NAME ROSALINA

MIDDLE NAME DURON (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE HIGHEST LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
UNITS ACADEMIC
LEVEL (Write in full) EARNED
GRADUATED
HONORS
(Write in full) (if not graduated) RECEIVED
From To
 ELEMENTARY EAST BUNAWAN CENTRAL ELEMENTARY SCHOOL ELEMENTARY 6/131986 3/31/1990 GRADUATED 1990 N/A

AGUSAN DEL SUR STATE COLLEGE OF

SECONDARY HIGHSCHOOL GRADUATE 5/6/1992 3/29/1994 GRADUATED 1994 3RD HONORS
AGRICULTURAL TECHNOLOGY(ASSCAT)

VOCATIONAL / TRADE COURSE N/A N/A N/A N/A N/A N/A N/A

SURIGAO DEL SUR POLYTECHNIC STATE

COLLEGE BEED 6/25/2004 3/29/2007 229 UNITS 2007 N/A
COLLEGE
UNIVERSITY OF SOUTHEASTERN SPED TRAINING SCHOLARSHIP TO BE
GRADUATE STUDIES 8/5/2012 8/6/2012 9 UNITS N/A
PHILIPPINES(USEP) SPECIALIZING LEARNING DISABILITY CONTINUED
(Continue on separate sheet if necessary)

SIGNATURE DATE
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 76.20 08/26/2007 CAGAYAN DE ORO 0967522 5/6/2020

(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
SERVICE
28. INCLUSIVE DATES SALARY/ JOB/
(mm/dd/yyyy) PAY GRADE (if
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
MONTHLY applicable)& STATUS OF
(Write in (Write in full/Do not
SALARY STEP (Format APPOINTMENT
full/Do not abbreviate) abbreviate)
From To "00-0")/
INCREMENT
(Y/
REGULAR- N)
01/01/2021 PRESENT SPET-1 DEPARTMENT OF EDUCATION 29,969.00 14-3 Y
PERMANENT
REGULAR-
01/01/2019 12/31/2019 SPET-1 DEPARTMENT OF EDUCATION 28,447.00 14-3 Y
PERMANENT
REGULAR-
03/06/2018 12/31/2018 SPET-1 DEPARTMENT OF EDUCATION 27,122.00 14-3 Y
PERMANENT
REGULAR-
01/01/2018 03/05/2018 SPET-1 DEPARTMENT OF EDUCATION 26,806.00 14-2 Y
PERMANENT
REGULAR-
01/01/2017 12/31/2017 SPET-1 DEPARTMENT OF EDUCATION 25,573.00 14-2 Y
PERMANENT
REGULAR-
01/01/2016 12/31/2016 SPET-1 DEPARTMENT OF EDUCATION 24,396.00 14-2 Y
PERMANENT
REGULAR-
03/06/2015 12/31/2015 SPET-1 DEPARTMENT OF EDUCATION 23,274.00 14-2 Y
PERMANENT
REGULAR-
06/01/2012 03/05/2015 SPET-1 DEPARTMENT OF EDUCATION 23,044.00 14-1 Y
PERMANENT
REGULAR-
03/06/2012 05/31/2012 SPET-1 DEPARTMENT OF EDUCATION 21,078.00 14-1 Y
PERMANENT
REGULAR-
06/01/2011 03/05/2012 T-1 DEPARTMENT OF EDUCATION 17,099.00 Y
PERMANENT
REGULAR-
06/24/2010 05/31/2011 T-1 DEPARTMENT OF EDUCATION 15,649.00 Y
PERMANENT
REGULAR-
08/03/2009 06/23/2010 T-1 DEPARTMENT OF EDUCATION 14,198.00 Y
PERMANENT
DEPED(KINDERGARTEN
DEPARTMENT OF EDUCATION
10/28/2007 03/27/2008 CONTRACTUAL TEACHER) 6,000.00 N/A CONTRACTUAL Y
BAYABAS HOPE CHRISTIAN COMMUNITY
06/05/2007 10/27/2008 NURSERY ADVISER SCHOOL 4,000.00 N/A CONTRACTUAL N

(Continue on separate sheet if necessary)

SIGNATURE DATE June 14,2021

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 NUMBER OF ( Managerial/ CONDUCTED/ SPONSORED BY
(Write in full) (mm/dd/yyyy) HOURS Supervisory/ (Write in full)
Technical/etc)
From To

THREE-DAY WORKSHOP ON QUALITY ASSURANCE,ILLUSTRATION AND LAY-OUTING OF

CONTEXTUALIZED LEARNING RESOURCES IN K-EMTB-MLE AND FILIPINO
01/18/2020 OI/20/2020 32 HRS TECHNICAL DEPED TANDAG CITY

ENHANCEMENT SEMINAR WORKSHOP ON TEST CONSTRUCTION IN ALL SUBJECT AREAS 12/19/2019 12/20/2019 24 HRS TECHNICAL DEPED TANDAG CITY

THREE-DAY WORKSHOP ON QUALITY ASSURANCE,ILLUSTRATION AND LAY-OUTING OF

CONTEXTUALIZED LEARNING RESOURCES IN K-EMTB-MLE AND FILIPINO
11/13/2019 11/15/2019 24 HRS TECHNICAL DEPED TANDAG CITY

CAPACITY BUILDING ON DESIGNING LEARNING ACTION CELL FOR EDUCATION PROGRAM

SUERVISORS,DISTRICST IN- CHARGE,SCHOOL HEADS,SLAC FACILITATORS AND SLAC MEMBERS
11/28/2019 11/30/2019 32 HRS TECHNICAL DEPED TANDAG CITY

2ND CITY DIVISION GSP ENCAMPMENT 10/18/2019 10/20/2019 32 HRS TECHNICAL DEPED TANDAG CITY

ONE-DAY DISTRICT WIDE SEMINAR WORKSHOP ON SUB-TASKING OF LEARNING

07/31/2019 07/31/2019 8 HRS TECHNICAL DEPED TANDAG CITY
COMPETENCIES ACROSS LEARNING AREAS

CARAGA CONGRESS O7/10/2015 10/7/2019 8 HRS TECHNICAL DEPED TANDAG CITY

5 DAY DIVISION WEBINAR IN ENHANCING TEACHING DELIVERY THROUGH RADION

1/12/2020 7/12/2020 TECHNICAL DEPED TANDAG CITY
BASED INSTRUCTION (RBI)
40 HRS

(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 DANCE TROUPE CHOREOGRAPHER

WRITING BIGBOOK WRITER( SI KULOT NA MAY NAPULOT)

 (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
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten

name tag and signature over
printed name

Computer generated
42. or photocopied picture
I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and 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: UMID NO.006-0075-4339-9

ID/License/Passport No.: 0967522 Signature (Sign inside the box)

Date/Place of Issuance: 01/11/2008/ BUTUAN 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