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 PALACIO
NAME EXTENSION (JR., SR) N/A
FIRST NAME ORPHA JHAELLE

MIDDLE NAME BENIGA

3. DATE OF BIRTH
(mm/dd/yyyy) 04/28/1992 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH BUUG, ZAMBOANGA SIBUGAY 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 BAGONG BUHAY
Widowed Separated House/Block/Lot No. Street
DITORAY
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 1.59 m PAGADIAN CITY ZAMBOANGA DEL SUR
City/Municipality Province
8. WEIGHT (kg) 60 kg ZIP CODE 7016

9. BLOOD TYPE A
18. PERMANENT ADDRESS 0826 PUROK MAKABIBIHAG
House/Block/Lot No. Street

10. GSIS ID NO. 2005405677 BALANGASAN

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1211-669705-33 PAGADIAN CITY ZAMBOANGA DEL SUR

City/Municipality Province

12. PHILHEALTH NO. 14-025169389-3 ZIP CODE 7016

13. SSS NO. 1011878893 19. TELEPHONE NO. N/A

14. TIN NO. 348473741 20. MOBILE NO. 09301444571/09153937800

15. AGENCY EMPLOYEE NO. 6276671 21. E-MAIL ADDRESS (if any) benigaorphajhaelle@gmail.com/orphajhaelle.palacio@deped.gov.ph

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME PALACIO 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME JUNIE N/A NESHAMAH ZECHARE BENIGA PALACIO 10/18/17

MIDDLE NAME LANDEZA

OCCUPATION NONE

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME BENIGA (Deceased)

NAME EXTENSION (JR., SR)
FIRST NAME EUSEBIO JR.

MIDDLE NAME PALONG-PALONG

25. MOTHER'S MAIDEN NAME

SURNAME AMORES

FIRST NAME ANNIE

MIDDLE NAME LAGOS (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

BUUG PILOT CENTRAL ELEMENTARY

ELEMENTARY PRIMARY EDUCATION 2003 2004 GRADUATED 2004 N/A
SCHOOL

VOCATIONAL ZAMBOANGA DEL SUR NATIONAL HIGH

SECONDARY / SECONDARY EDUCATION 2004 2008 GRADUATED 2008 N/A
SCHOOL STA. LUCIA ANNEX

N/A N/A N/A N/A N/A N/A N/A

TRADE WESTERN MINDANAO STATE
COURSE
COLLEGE UNIVERSITY EXTERNAL STUDIES UNIT - BACHELOR IN ELEMENTARY EDUCATION 2008 2012 GRADUATED 2012 N/A
PAGADIAN CITY
GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A

SIGNATURE DATE 02/26/2020 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 82.80% 09/30/2012 PAGADIAN CITY 1387913 04/28/2021

(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
SALARY/ JOB/ SERVICE
28. INCLUSIVE DATES PAY GRADE (if
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY applicable)& STATUS OF
(Write in full/Do not (Write in SALARY STEP (Format APPOINTMENT
abbreviate) full/Do not abbreviate) "00-0")/
From To INCREMENT
(Y/ N)
DEPARTMENT OF EDUCATION PAGADIAN REGULAR/
06/20/2018 PRESENT TEACHER 1 20,754 PERMANENT
YES
CITY DIVISION
06/13/2017 08/31/2017 TEACHER HAPPY HEARTS MONTESSORI 7000 PROVISIONAL NO

03/04/2017 05/31/2017 TEACHER HAPPY HEARTS MONTESSORI 7000 PROVISIONAL NO

06/13/2016 03/31/2017 TEACHER HAPPY HEARTS MONTESSORI 7000 PROVISIONAL NO

1/4/2016 05/31/2017 TEACHER HAPPY HEARTS MONTESSORI 7000.00 PROVISIONAL NO

8/2/2016 03/30/2016 TEACHER HAPPY HEARTS MONTESSORI 7000.00 PROVISIONAL NO

SIGNATURE DATE 02/26/2020 CS FORM 212 (Revised 2017), Page 2 of 4

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
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

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

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) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To
January 22, January 24,
Psycological First Aid Training for School DRRM Coordinators 24 TECHNICAL DEPARTMENT OF EDUCATION
2020 2020
Occupational First Aid and Basic Life Support for School DRRM Coordinators/First aid November 11, November 13,
24 TECHNICAL DEPARTMENT OF EDUCATION
Responders 2019 2019
3-Day Contingency Planning Training for School Disaster Risk Reduction and November 6, November 8,
24 TECHNICAL DEPARTMENT OF EDUCATION
Management Coordinators 2019 2019
October 23, October 25,
Cluster In-Service Training and Midyear Performance Review and Evaluation 24 TECHNICAL DEPARTMENT OF EDUCATION
2019 2019
Two-Day Division Enhancement Training Workshop for School Paper Advisers on September 5, September 6,
16 TECHNICAL DEPARTMENT OF EDUCATION
Journalism 2019 2019
3-Day Live-Out Division Professional Development Training For Elementary And Secondary
School Teachers On Pedagogy And Content Cum Assessment
May 15, 2019 May 17, 2019 24 TECHNICAL DEPARTMENT OF EDUCATION

3-Day Training on Parliamentary Procedures and Workshop on Resolution-Making, Official

Communications and Minutes-Writing for SSG/SPG Teacher-Advisers March 22, 2019 March 24, 2019 24 TECHNICAL DEPARTMENT OF EDUCATION

3-Day Seminar-Workshop on Teacher Induction Program Policy Implementation For Newly-Hired

Teacher
March 8, 2019 March 10, 2019 24 TECHNICAL DEPARTMENT OF EDUCATION

February 12, February 12,

Division Orientation-Workshop on the Use and Manipulation of Microscope 24 TECHNICAL DEPARTMENT OF EDUCATION
2019 2019
October 15, November 19,
Professional Development For Teacher Trainers 24 TECHNICAL Arizona State University in partnership with Canvas Network
2018 2018
3-DayBasic Incident Command System Course Training for Schools Disaster Risk Reduction and November 7, November 9, DEPARTMENT OF EDUCATION in partnership with Office Of Civil Defense
Management Coordinators
24 TECHNICAL Regional Disaster Risk Reduction And Management Council
2018 2019
DEPARTMENT OF EDUCATION Regional Office IX-Zamboanga
Regional Disaster Risk Reduction and Management Caravan Oct. 26, 2018 Oct. 26, 2018 8 TECHNICAL Peninsula

Orientation of R.A. 7610 "Special Protection of Children Against Abuse, Exploitation and Discrimination Act" September 24, September 26,
24 TECHNICAL DEPARTMENT OF EDUCATION
and R.A. 10627 "Anti-Bullying Act" 2019 2018
Cluster 2 - South District Orientation on Results-Based Performance Management System (RPMS) Cum PPST August 15,
August 17,
for Teachers 24 TECHNICAL DEPARTMENT OF EDUCATION
2018
2019
August 7, DEPARTMENT OF EDUCATION in partnership with Office Of Civil Defense
2-Day Contingency Planning Training For Schools Disaster Risk Reduction And Management Coordinators August 6, 2018 16 TECHNICAL Regional Disaster Risk Reduction And Management Council
2018
Division Retooling on Unpacking Learning Competencies and Writeshop of Daily Lesson Log for August 4,
Science 3, 4, 5, 6
August 3, 2018 16 TECHNICAL DEPARTMENT OF EDUCATION
2018
BOY SCOUTS OF THE PHILIPPINES ZAMBOANGA DEL SUR -
Basic Training Course For Troop Leaders July 26, 2018 July 28, 2018 55 TECHNICAL PAGADIAN CITY COUNCIL

Music Education Seminar - Workshop For Teachers in Grade 4, 5, 6 July 4, 2018 July 6, 2018 24 TECHNICAL DEPARTMENT OF EDUCATION

(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)

DANCING N/A City South District Teachers Association

COOKING

(Continue on separate sheet if necessary)

SIGNATURE DATE 02/26/2020 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 ✘ 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? ________________________________
RESIGNATION
________________________________
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
FE A. BIBANCO PAGADIAN CITY the last 6 months
3.5 cm. X 4.5 cm
(passport size)
JESSIE FERNAN PAGADIAN CITY 9209682114
With full and handwritten
ARD CATALINO PAGADIAN CITY 9209757609 name tag and signature over
printed name
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete Computer generated
statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. I or photocopied picture
is not acceptable
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 administrative/criminal case/s PHOTO
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/License/Passport No.: 1287913 Signature (Sign inside the box)
02/26/2020
Date/Place of Issuance: 04/17/2018/PAGADIAN CITY Date Accomplished Right Thumbmark

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

EMILIA O. ZOZOBRADO
Person Administering Oath

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

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