CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

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 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 COROTAN
NAME EXTENSION (JR., SR)
FIRST NAME ANNA VANESSA

MIDDLE NAME VALDEMOR

3. DATE OF BIRTH
(mm/dd/yyyy) JUNE 21,1990 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by birth by naturalization
MATILDE A. OLIVAS DISTRICT HOSPITAL
4. PLACE OF BIRTH
CAMALANIUGAN CAGAYAN
If holder of dual citizenship, Pls. indicate country:

please indicate the details.

5. SEX Male ✘ Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS #169 ZONE 1

House/Block/Lot No. Street
Widowed Separated
CATAYAUAN
Other/s: Subdivision/Village Barangay
LAL-LO CAGAYAN
7. HEIGHT (m) 1.25
City/Municipality Province
8. WEIGHT (kg) 43 ZIP CODE 3509

18. PERMANENT ADDRESS #169 ZONE 1

9. BLOOD TYPE AB+
House/Block/Lot No. Street
CATAYAUAN
10. GSIS ID NO.
Subdivision/Village Barangay
LAL-LO CAGAYAN
11. PAG-IBIG ID NO.
City/Municipality Province

12. PHILHEALTH NO. ZIP CODE 3509

13. SSS NO. 19. TELEPHONE NO. none

14. TIN NO. 20. MOBILE NO. 09068395470

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) anna.vane24@gmail.com
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) BEEANNE IZZY C. LANNAO

FIRST NAME N/A 4/15/2013

MIDDLE NAME N/A

OCCUPATION N/A
EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME COROTAN

NAME EXTENSION (JR., SR)
FIRST NAME FREDY

MIDDLE NAME CARILLO

25. MOTHER'S MAIDEN NAME GUILLERMO

SURNAME COROTAN

FIRST NAME JOAN

MIDDLE NAME VALDEMOR (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY CATAYAUAN ELEM. SCHOOL PRIMARY EDUCATION 1996 2003 2003

VOCATIONAL
SECONDARY / LALLO NATIONAL HIGH SCHOOL HIGH SCHOOL 2003 2007 2007

TRADE
COURSE CAGAYAN STATE UNIVERSITY TUGUEGARAO
COLLEGE
CITY CARIG CAMPUS
BACHELOR OF SCIENCE IN BIOLOGY 2007 2011 2011

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE November 11, 2021

CS FORM 212 (Revised 2017), Page 1 of 6

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL DATE OF LICENSE (if applicable)
RATING
LAWS/ CES/ CSEE BARANGAY EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity

(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.
SALARY/ GOV'T
28. INCLUSIVE DATES JOB/ PAY SERVICE
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in SALARY
applicable)&
APPOINTMENT
STEP (Format
full/Do not abbreviate) (Write in full/Do not abbreviate) "00-0")/
From To INCREMENT
(Y/ N)
DEPARTMENT OF THE INTERIOR AND
Feb. 2021 PRESENT CONTACT TRACER 18,784.00 9 CONTRACTUAL YES
LOCAL GOVERNMENT
DEPARTMENT OF THE INTERIOR AND
Oct. 2020 Dec. 2020 CONTACT TRACER 18,784.00 9 CONTRACTUAL YES
LOCAL GOVERNMENT
TYRO SORTA GUN CLUB AND SHOOTING
Sep. 2018 Dec. 2019 HEAD SECRETARY 19,862.00 RESIGNED NO
RANGE INC.
GMI- MONDE NISSIN DEPARTMENT(LAL-LO
Jan. 2018 July 2018 SALES CLERK 9,672.00 END CONTRACT NO
S.O)

ORDER PROCESSING ANLYST/ PEPSI COLA PRODUCT PHILIPPINES. INC.

MARCH 2015 APRIL 2017 13,000.00 PERMANENT NO
TERRITORY COORDINATOR (ARCHWAY/LAVELLE VIE AGENCY)

PEPSI COLA PRODUCT PHILIPPINES. INC.

MAY 2014 Mar. 2015 ORDER PROCESSISNG ANALYST 13,000.00 PERMANENT NO
(ARCHWAY AGENCY)

PEPSI COLA PRODUCT PHILIPPINES. INC.

MAY 2012 Dec. 2012 ROUTE SETTLEMENT ANALYST 13,000.00 PERMANENT NO
(ARCHWAY AGENCY)
SANFORD MARKETING (SAVEMORE
Nov. 2011 MAY 2012 CASHIER 6,760.00 END CONTRACT NO
TUGUEGARAO)

(Continue on separate sheet if necessary)

SIGNATURE DATE November 11, 2021
CS FORM 212 (Revised 2017), Page 2 of 6
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

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

TRANING FOR NEWLY HIRED CONTACT TRACERS 8/30/21 8/30/21

PAGSASAGAWA NG CONTACT TRACING TRAINING 9/30/21 9/30/21

(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)

COMPUTER LITERATE

HIGHLY ADAPTABLE TO WORK

ENVIRONMENT

ABOVE-AVERAGE
COMMUNICATION AND
ANALYTICAL SKILLS

PLAYING BASKETBALL

(Continue on separate sheet if necessary)

SIGNATURE DATE November 11,2021

CS FORM 212 (Revised 2017), Page 3 of 6
 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
YES ✘ NO
or regulation by any court or tribunal?
If YES, give details:
________________________________
37. Have you ever been separated from the service in any of the following modes: ________________________________
YES ✘ NO
resignation, retirement, dropped from the rolls, dismissal, termination, end of term, If YES, give details:
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 ________________________________
YES ✘ NO
year (except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period YES NO
before the last 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
YES ✘ NO
country?
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
a. answer
Are you the followingofitems:
a member 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: 015

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

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
HON. FLORENCE OLIVER B. PASCUAL LGU-LAL-LO 9175669669 3.5 cm. X 4.5 cm
(passport size)

MS. ROSHSEINEE O. GUMABAO MLGOO LAL-LO, CAGAYAN 9173119723 With full and handwritten
name tag and signature
DILG-CLUSTER OFFICE, NORTHERN over
RICARDO CP TORRADO CAGAYAN
9159110221 printed name

42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, Computer generated
or photocopied picture
correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of is not acceptable
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 PHOTO
document and its attachments shall cause the filing of 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: DILG ID
ID/License/Passport No.: 2387
Signature (Sign inside the box)
Date/Place of Issuance: TUGUEGARAO CITY November 11, 2021
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 6 of 6