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 ANDAYA
NAME EXTENSION (JR., SR)
FIRST NAME LYRA

MIDDLE NAME MERJUDIO

3. DATE OF BIRTH
(mm/dd/yyyy) 5/31/1996 16. CITIZENSHIP ✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH MAUBAN, QUEZON If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

✘ Single Married 17. RESIDENTIAL ADDRESS MALUBAY STREET

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
BAGONG BAYAN
Other/s:
Subdivision/Village Barangay
MAUBAN QUEZON
7. HEIGHT (m) 1.48
City/Municipality Province
8. WEIGHT (kg) 36 ZIP CODE 4330
18. PERMANENT ADDRESS MALUBAY STREET
9. BLOOD TYPE
House/Block/Lot No. Street
BAGONG BAYAN
10. GSIS ID NO. N/A
Subdivision/Village Barangay
MAUBAN QUEZON
11. PAG-IBIG ID NO. N/A
City/Municipality Province
12. PHILHEALTH NO. N/A ZIP CODE 4330

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

14. TIN NO. 358-192-166-000 20. MOBILE NO. 09109609074

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) andayalyra28@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)
FIRST NAME N/A N/A N/A

MIDDLE NAME N/A N/A N/A

OCCUPATION N/A N/A N/A

EMPLOYER/BUSINESS NAME N/A N/A N/A

BUSINESS ADDRESS N/A N/A N/A

TELEPHONE NO. N/A N/A N/A

24. FATHER'S SURNAME ANDAYA

NAME EXTENSION (JR., SR)
FIRST NAME LYRA
PEÑAFLORIDA
MIDDLE NAME

25. MOTHER'S MAIDEN NAME

SURNAME MERJUDIO

FIRST NAME MARITES

MIDDLE NAME OREJOLA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
UNITS ACADEMIC
LEVEL (Write in full) EARNED
GRADUATED
HONORS
(Write in full) (if not RECEIVED
From To
graduated)
ELEMENTARY BAGONG BAYAN ELEM. SCHOOL PRIMARY EDUCATION 2004 2009 N/A 2009 N/A
VOCATIONAL /
SECONDARY THE SISTERS OF MARY SCHOOL HIGHSCHOOL 2009 2012 N/A 2012 N/A

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

COLLEGE TRADE
SUAREZ
COURSE
PAMBAYANG KOLEHIYO NG MAUBAN BACHELOR OF ELEMENTARY EDUCATION 2015 2019 N/A 2019 SCHOLARSHIP

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE December 8, 2020

CS FORM 212 (Revised 2017), Page 1 of 4

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

(PRC) LICENSURE EXAMINATION FOR TEACHER 76.6 9/29/2019 LUCENA CITY 19-2423089

(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. SALARY/ JOB/
INCLUSIVE DATES (mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY PAY GRADE (if
MONTHLY STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To

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

(Continue on separate sheet if necessary)

SIGNATURE DATE DECEMBER 8,2020

CS FORM 212 (Revi
 LICENSE (if applicable)

Date of
Validity

5/31/2023

parate sheet if necessary)

GOV'T SERVICE

(Y/ N)

N/A

parate sheet if necessary)

DECEMBER 8,2020
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (Write in
full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To
PHILIPPINE ASSOCIATION FOR TEACHERS
5/15/2019 UP TO DATE N/A MEMBER
EDUCATION (PAFTE)
SERBISYONG SUAREZ SCHOLARSHIP 7/10/2015 5/31/2019 N/A MEMBER

SOCIETY OF ELEMENTARY EDUCATORS 7/1/2016 5/30/2019 N/A MEMBER

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

ICT TRAINING FOR EDUCATORS 10/7/2019 10/18/2019 70.0 TECHNICAL MAUBAN-LEARNING VILLE

TECH4ED EEDUSKILLS (HOUSEKEEPING) 10/07/2019 10/18/2019 10.0 TEACHNICAL

MAUBAN-LEARNING VILLE

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 33.
(Write in full) (Write in
full)
Technical Skills (including Computer Literacy Skills)

SEWING GARMENTS

(Continue on separate sheet if necessary)

SIGNATURE DATE DECEMBER 8,2020

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
YES ✘ NO
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: resignation, YES ✘ NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or If YES, give details:
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 YES ✘ NO
(except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
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 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
J If YES, please specify ID No:
O
c.S Are you a solo parent? YES ✘ NO
E 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
MARIA DIANA VALDEZ JOSE LUCENA,CITY 9985475086 3.5 cm. X 4.5 cm
(passport size)

With full and handwritten

name tag and signature over
printed name

Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied picture
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 PHOTO
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: PRC LICENSED ID

ID/License/Passport No.: 19-2423089

Signature (Sign inside the box)

Date/Place of Issuance: Lucena City

December 8,2020
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