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 DANGARAN
FIRST NAME ROGIE N/A
MIDDLE NAME BULITIC
3.
16. CITIZENSHIP
DATE OF BIRTH ✘ Filipino Dual Citizenship
(mm/dd/yyyy) 3/11/1995
✘ by birth by naturalization

4. PLACE OF BIRTH Pagadian City 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 MALIPAYON
Widowed Separated House/Block/Lot No. Street
SUMADAT
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 1.67 DUMALINAO ZAMBOANGA DEL SUR
City/Municipality Province
8. WEIGHT (kg) 60 ZIP CODE 7015

9. BLOOD TYPE O+
18. PERMANENT ADDRESS PUROK MALIPAYON
House/Block/Lot No. Street

10. GSIS ID NO. N/A SUMADAT

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1212-2878-1339 DUMALINAO ZAMBOANGA DEL SUR

City/Municipality Province
12. PHILHEALTH NO. 140502394122 ZIP CODE 7015
13. SSS NO. 10-1286771-9 19. TELEPHONE NO. N/A
14. TIN NO. 482-736-781 20. MOBILE NO. 09129677620
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) rogiedangaran@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)

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 DANGARAN N/A N/A
FIRST NAME ROMUALDO N/A N/A
MIDDLE NAME SESDYERO N/A N/A
25. MOTHER'S MAIDEN NAME BULITIC N/A N/A
SURNAME DANGARAN N/A N/A
FIRST NAME VIRGINIA N/A N/A
MIDDLE NAME TUNDAY (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

26. NAME OF SCHOOL PERIOD OF ATTENDANCE HIGHEST LEVEL/ SCHOLARSHIP/

YEAR
BASIC EDUCATION/DEGREE/COURSE UNITS ACADEMIC
LEVEL (Write in EARNED
GRADUATED
(Write in full) HONORS
full) (if not graduated) RECEIVED
From To

WITH
ELEMENTARY SUMADAT ELEMENTARY SCHOOL PRIMARY 2002 2008 GRADUATED 2008
HONORS
VOCATIONAL
SECONDARY / IMMACULATE HEART ACADDEMY SECONDARY 2008 2012 GRADUATED 2012 N/A
WEST PRIME HORIZON INSTITUTE INC.
COMPUTER LITERACY 2018 2018 GRADUATED 2018 NCII
(TESDA)
TRADE J.H CERILLES STATE COLLEGE- BACHELOR OF SECONDARY
COLLEGE
COURSE 2012 2017 GRADUATED 2017 N/A
DUMALINAO CAMPUS EDUCATION

(Continue on separate sheet if necessary)

SIGNATURE DATE November 24, 2022

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 76.4 9/24/2017 PAGADIAN CITY 1562652 03/112023

(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
28. INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)
IMMACULATE HEART ACADEMY OF DUMALINAO
07/04/2018 05/31/2022 TEACHER INC.
₱9,800 CONTRACTUAL N0

03/01/2016 09/09/2016 ASSISTANT DUMALINAO CIVIL REGISTRY (DOLE GIP) ₱6,000 CONTRACTUAL YES

(Continue on separate sheet if necessary)

SIGNATURE DATE NOVEMBER 24, 2022

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 NUMBER OF
(Write in full) (mm/dd/yyyy) HOURS POSITION / NATURE OF WORK
From To

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
NUMBER OF (Managerial/ CONDUCTED/ SPON
INTERVENTIONS/TRAINING PROGRAMS HOURS Supervisory/
(Write in full) (mm/dd/yyyy)
Technical/etc)
From To (Write in
Microsoft Digital Literacy 6/11/2022 11/1/2022 15 HRS. TECHNICAL TECHNICAL EDUCATION AND S

Conducting Competency Assessment 10/19/2022 11/1/2022 84 HRS. MANAGERIAL TECHNICAL EDUCATION AND S

Maintaining Training Facilities 10/19/2022 11/1/2022 84 HRS. MANAGERIAL TECHNICAL EDUCATION AND S

Supervising Work-Based Learning 10/19/2022 11/1/2022 84 HRS. SUPERVISOR TECHNICAL EDUCATION AND S

Utilizing Electronic Media in Facilitating Training 10/19/2022 11/1/2022 84 HRS. TECHNICAL TECHNICAL EDUCATION AND S
Supervising
PLANNING Work-Based Learning
TRAINING SESSION 10/7/2022 10/20/2022 84 HRS. MANAGERIAL TECHNICAL EDUCATION AND S
Supervising Work-Based Learning
TECHNOLOGY Supervising Work-Based
INTEGRATION IN ALearning
HYBRID SET-UP 01/08/2022 01/08/2022 2 HRS. TECHNICAL KAAGAPAY TEACHER
Supervising Work-Based Learning
INTERNET Supervising
AND MEDIA Work-Based
INFORMATION Learning
LITERACY DEPARTMENT OF INFOR
SupervisingTRAINING
Work-Based Learning 02/17/2022 02/17/2022 3 HRS. TECHNICAL COMMUNICATIONS TEC
Supervising Work-Based Learning
Supervising Work-Based Learning
SMART Technopreneurship 101 02/02/2022 02/11/2022 70 HRS.. TECHNICAL TECHNICAL EDUCATION AND S
2021 IN-SERVICE TRAINING (INSET) FOR SENIOR HIGH
SCHOOL TEACHERS ( THEME: FACILITATING LEARNING 07/24/2021 07/26/2021 24 HRS. SUPERVISORY Private Education Assistan
IN AFLEXIBLE CLASS)
PRACTICING COVID-19 PREVENTIVE MEASURES IN THE TECHNICAL EDUUCATION
10/22/2021 10/22/2021 8 HRS. MANAGERIAL DEVELOPMENT AUT
WORKPLACE
2020 IN SERVICE TRAINIG (INSET) FOR JUNIOR HIGH
09/07/2020 09/09/2020 24 HRS. SUPERVISORY Private Education Assistan
SCHOOL TEACHER
MEDIA INFORMATION LITERACY, VIDEO PRODUCTION
& DIGITAL PHOTOGRAPHY AND DIGITAL ARTS IN 04/29/2019 05/01/2019 24 HRS. TECHNICAL TECHFACTORS
PHOTOSHOP
2019 SUMMER IN-SERVICE TRAINING (INSET) FOR
JUNIOR HIGH SCHOOL TEACHERS DESIGNING,
04/08/2019 04/10/2019 24 hrs. SUPERVISORY Private Education Assistan
ASSESSING AND FACILITATING LEARNING OF THE K-12
2019 SUMMER WITH
STANDARDS IN-SERVICE TRAINING
21ST CNTURY (INSET) FOR
PEDAGOGIES
SENIOR HIGH SCHOOLTEACHERS (ENSURING SHS
04/12/2019 04/14/2019 24 HRS. SUPERVISORY Private Education Assistan
LEARNERS PREPARATION FOR FOUR EXITS OF K-12
CURRICULUM
TECHNICAL EDUUCATION
COMPUTER SYSTEM SERVICING (CSS) NC II 03/12/2018 04/24/2018 280 HRS. TECHNICAL DEVELOPMENT AUT
TO EQUIP THE STUDENTS WITH ICT TECHNICAL SKILLS DEPARTMENT OF INFOR
08/16/2017 10/17/2017 480 HRS. TECHNICAL COMMUNICATIONS TEC
FOR ONLINE FREE LANCING INDUSTRY

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATIO
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)
(Write in fu

COMPUTER LITERATE N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE November 24, 2

CS FORM 212 (Revis

 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 by any court
YES ✘ NO
or tribunal?
If YES, give details:
________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped YES ✘ NO
from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in the public or If YES, give details:
private sector? ________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except Barangay
YES ✘ NO
election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last election to YES ✘ NO
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
SUMADAT DUMALINAO ZAMBOANGA the last 6 months
MR. ERMIE LOU PEREGRINE BONGABONG 9380250010 3.5 cm. X 4.5 cm
DEL SUR (passport size)

PAG-LAUM, DUMALINAO With full and handwritten

MR. DANTE O. DEL MUNDO 9462643536 name tag and signature over
ZAMBOANGA DEL SUR printed name
PAG-ASA, DUMALINAO
MRS. REGINA I. CUIZON 9309195350 Computer generated
AMBOANGADEL SUR DEL SUR or photocopied picture
is not acceptable
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and 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 administrative/criminal case/s against me. PHOTO

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of Issuance

Government Issued ID: PROFESSIONAL LICENSE ID

ID/License/Passport No.: 1562652 Signature (Sign inside the box)

November 24, 2022
Date/Place of Issuance: 12/06/2017/ PAGADIAN 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