CS Form No.

212

PERSONAL DATA SHEET

Revised 2017

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 PALENCIA
N/A
FIRST NAME CORY JANE
MIDDLE NAME REGUYA
3. DATE OF BIRTH
(mm/dd/yyyy) 6/25/1986 16. CITIZENSHIP Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH COMPOSTELA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female

6 CIVIL STATUS Single Married 17. RESIDENTIAL ADDRESS N/A 4TH STREET
Widowed Separated House/Block/Lot No. Street
MSU-MAIN
Other/s:
Subdivision/Village Barangay

7. HEIGHT (m) 1.22 m MARAWI CITY LANAO DEL SUR

City/Municipality Province
8. WEIGHT (kg) 55 kg ZIP CODE 9700

9. BLOOD TYPE "O" 18. PERMANENT ADDRESS N/A PUROK ORCHIDS

House/Block/Lot No. Street

10. GSIS ID NO. 0200-431-1592 PUROK ORCHIDS TENAZAS

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 0200-431-1592 LALA LANAO DEL NORTE

City/Municipality Province

12. PHILHEALTH NO. 2000--0008-6486 ZIP CODE 9211

13. SSS NO. 1211-5218-1193 19. TELEPHONE NO. N/A

14. TIN NO. 949-668-10179 20. MOBILE NO. 0948-913-6834
15. AGENCY EMPLOYEE NO. 15249 21. E-MAIL ADDRESS (if any) coryjanepalencia@yahoo.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME PALENCIA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME OSCAR N/A XIAMARA ELLYZE R. PALENCIA 12/31/2015

MIDDLE NAME PAGTALUNAN REEVANNAH DANE R. PALENCIA 5/15/2017
OCCUPATION AGRICULTURAL TECNICIAN

EMPLOYER/BUSINESS NAME DEPARMENT OF AGRICULTURE -OMAS

DEPARTMENT OF AGRICULTURE, LOCAL GOVERNMENT UNIT,
BUSINESS ADDRESS
LALA, LANAO DEL NORTE
TELEPHONE NO. GG-

24. FATHER'S SURNAME PALENCIA

FIRST NAME MAXIMINO N/A

MIDDLE NAME MANDANTES

25. MOTHER'S MAIDEN NAME REMIS
SURNAME REGUYA
FIRST NAME ALICIA
MIDDLE NAME GADIA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST LEVEL/ SCHOLARSHIP/
26. NAME OF SCHOOL PERIOD OF ATTENDANCE
BASIC EDUCATION/DEGREE/COURSE UNITS YEAR ACADEMIC
LEVEL
(Write in full) EARNED GRADUATED HONORS
(Write in full) (if not graduated) RECEIVED
From To
COMPOSTELA CENTRAL ELEMENTARY
ELEMENTARY ELEMENTARY 6/30/1992 6/30/1999 N/A 1999 WITH HONOR
SCHOOL

SECONDARY COMPOSTELA NATIONAL HIGH SCHOOL SECONDARY 6/30/1999 6/30/2003 N/A 2003 WITH HONOR
VOCATIONAL /
N/A N/A N/A N/A N/A N/A WITH HONOR

MINDANAO STATE UNIVERSITY, CULTURAL

COLLEGE TERTIARY 6/30/2003 6/30/2009 N/A 2009
MARAWI CITY GRANTEE
MINDANAO STATE UNIVERSITY,
GRADUATE STUDIES GRADUATE 6/30/2009 6/30/2015 N/A 2015 N/A
MARAWI CITY
(Continue on separate sheet if necessary)

SIGNATURE DATE June 15, 2020

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

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

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

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

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

COLLEGE OF SPORTS, PHYSICAL NBC 579

1/1/2020 12/31/2020 ASSISSTANT PROFESSOR IV 42662.00 REGULAR Y
EDUCATION AND RECREATION (1T)
COLLEGE OF SPORTS, PHYSICAL EO 201
1/1/2019 12/31/2019 ASSISSTANT PROFESSOR IV 41140.00 REGULAR Y
EDUCATION AND RECREATION (4TH) S.I.
COLLEGE OF SPORTS, PHYSICAL
1/1/2018 12/31/2018 ASSISSTANT PROFESSOR IV 38085.00 EO 201 (3T) REGULAR Y
EDUCATION AND RECREATION
COLLEGE OF SPORTS, PHYSICAL
12/1/2017 12/31/2017 ASSISSTANT PROFESSOR IV 35693.00 PROMOTION REGULAR Y
EDUCATION AND RECREATION
COLLEGE OF SPORTS, PHYSICAL
1/1/2017 12/31/2017 INSTRUCTOR I 21387.00 EO 201 (2T) REGULAR Y
EDUCATION AND RECREATION
COLLEGE OF SPORTS, PHYSICAL
1/1/2016 12/31/2016 INSTRUCTOR I 20651.00 EO 201 REGULAR Y
EDUCATION AND RECREATION
COLLEGE OF SPORTS, PHYSICAL CHANGE
6/1/2014 12/31/2016 INSTRUCTOR I 19940.00 REGULAR Y
EDUCATION AND RECREATION STATUS
COLLEGE OF SPORTS, PHYSICAL
1/1/2011 10/31/2013 INSTRUCTOR I 15119.00 RENEWAL CONTRACTUAL Y
EDUCATION AND RECREATION
COLLEGE OF SPORTS, PHYSICAL
1/1/2010 6/23/2010 INSTRUCTOR I 15119.00 RENEWAL CONTRACTUAL Y
EDUCATION AND RECREATION
COLLEGE OF SPORTS, PHYSICAL
6/15/2009 10/31/2009 INSTRUCTOR I 11167.00 RENEWAL CONTRACTUAL Y
EDUCATION AND RECREATION

(Continue on separate sheet if necessary)

SIGNATURE DATE June 15, 2020

CS FORM 212 (Revised 2017), Page 2 of 4

PROJECT H.
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
29. NAME & ADDRESS OF ORGANIZATION NUMBER OF
(Write in full) 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

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) HOURS Supervisory/ (Write in full)
Technical/etc)
From To

LANAO DEL SUR COACHES FORUM 12/7/2019 12/7/2019 6 SEMINAR ROOM 12, MSU GRANDSTAND, MARAWI CITY

VISION BEYOND BORDERS 2019 GRAND LECTURE 11/19/2019 11/19/2019 6 SEMINAR

MAMITUA SABER RESEARCH CENTER, MSU, MARAWI CITY
2-DAY CONSULTATIVE MEETING ON THE ESTABLISHMENT OF THE RESEARCH
6/13/2019 6/14/2019 12 TECHNICAL
ETHICS COMMITTEE (REC) AND RESEARCH IN-HOUSE REVIEW MAZE PARK, BURU-UN, ILIGAN CITY

BASIC RESEARCH ETHICS TRAINING “DATA PRIVACY IN RESEARCH” 4/15/2019 4/15/2019 6 TECHNICAL MAMITUA SABER RESEARCH CENTER, MSU, MARAWI CITY

SELECTED FACULTY AND STAFF OF THE UNIVERSITY TO ATTEND THE

8/11/2017 8/12/2017 12 TECHNICAL ILIGAN MEDICAL CENTER COLLEGE, ILIGAN CITY
MINDANAO PEACE GAMES COACHES AND STUDENT-ATHLETES FORUM

PHILIPPINE SPORTS INSTITUTE "CONSULTATIVE MEETING AND GRASSROOTS 5/22/2017 5/25/2017 30 SEMINAR CHARM PAVILLION, MSU, MARAWI CITY
COACHING PROGRAM"
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

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

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)

VIII. OTHER INFORMATION

33. MEMBERSHIP IN ASSOCIATION/ORGANIZATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32.
(Write in full)
(Write in full)
SINGING, DANCING AND DRAMA
N/A N/A
CHOREOGRAPHY
GARDENING N/A N/A

COOKING 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)

SIGNATURE DATE June 15, 2020

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
HENDLY A. ADLAWAN MARAWI CITY 0909-564-2382 3.5 cm. X 4.5 cm
(passport size)
HENRY C. DAUT ILIGAN CITY 0947-768-4105 With full and handwritten
name tag and signature over
printed name
PEPITO A. SUMAYAN MARAWI CITY 0918-732-4812
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 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: FACULTY ID

ID/License/Passport No.: 15249

Signature (Sign inside the box)
June 15, 2020
Date/Place of Issuance: DECEMBER 2019
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