CS Form No.

212
Revised 2017
PERSONAL DATA SHEET
WARNING: Any misrepresentation made in the Personal Data Sheet and the Work Experience Sheet sha ll 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 ACCOM PLISHING THE PDS FORM .
Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIAT E. 1. CS ID No. (Do not fill up. For CSC use only )

I. PERSONAL INFORMATION
2. SURNAME GOMEZ
NAM E EXTENSION (J R ., S R ) N/A
FIRST NAME PETER AL L EN

MIDDLE NAME HERNANDEZ

3. DATE OF BIRTH
01/23/1994 16. CITIZENSHIP
Filipino Dual Citizenship
(mm/dd/y y y y )
by birth by naturalization
POBLACION, SAN ANTONIO,
4. PLACE OF BIRTH If holder of dual citizenship, Pls. indicate country:
QUEZON
please indicate the details.
5. SEX Male Female

Single Married 17. RESIDENTIAL ADDRESS N/A N/A

6 CIVIL STATUS
Widowed House/Block/Lot No. Street
Separated
MARMAINE VILLE II PANSOL
Other/s:
Subdivision/Village Barangay
PADRE GARCIA BATANGAS
7. HEIGHT (m) 5'6''
City/Municipality Province
8. WEIGHT (kg) 52 KGS ZIP CODE 4224

18. PERMANENT ADDRESS N/A N/A

9. BLOOD TYPE O
House/Block/Lot No. Street
MARMAINE VILLE II PANSOL
10. GSIS ID NO. N/A
Subdivision/Village Barangay
PADRE GARCIA BATANGAS
11. PAG-IBIG ID NO. 1211-7535-8243
City/Municipality Province
12. PHILHEALTH NO. 08-051524942-0 ZIP CODE 4224

13. SSS NO. 04- 3775376-8 19. TELEPHONE NO. N/A

14. TIN NO. 496-470-319-000 20. MOBILE NO. 09984219766

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any ) gomezpeterallen30@gmail.com
II. FAMILY BACKGROUND
DATE OF BIRTH
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
(mm/dd/y y y y )
NAM E EXTENSION (J R ., S R ) N/A
FIRST NAME N/A N/A
N/A

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME GOMEZ

NAM E EXTENSION (J R ., S R )
FIRST NAME VIRGILIO N/A

MIDDLE NAME LIQUE

25. MOTHER'S MAIDEN NAME

SURNAME HERNANDEZ

FIRST NAME MHELEBETH

MIDDLE NAME DE MAALA (Conti nue o n sep arate sheet i f necessary)

III. EDUCATIONAL BACKGROUND

HIGHES T S C HOLAR S
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE P ERIOD OF ATTENDANC E LEVEL/
YEAR
HIP /
LEVEL UNITS AC ADEM IC
(Write in full) (Write in full) GRADUATED
EAR NED HONOR S
(if no t R EC EIVED
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) DATE OF LICENSE (if applicable)
RATING
UNDER SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT Date of
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT Validity
PROFESSIONAL REGULATION COMMISSION
75.2 09/24/2017 LUCENA 1721697 01/23/2025
- PROFESSIONAL TEACHER
NOTHING FOLLOWS

(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/
28. INCLUSIVE DATES DEPARTMENT / AGENCY / OFFICE / JOB/ PAY
POSITION TITLE GRADE (if S TATUS OF GOV'T
(mm/dd/y y y y ) COMPANY M ONTHLY
ap p licab le)& AP P OINTMEN S ER VIC E
(Write in full/Do not abbrev iate) SALARY
STEP T (Y/ N)
From (Write in full/Do not abbrev iate)
To (Fo rmat "0 0 -
0 ")/
11/24/2022 12/16/2022 Teacher 1 Pansol Integrated National High School 25439.00 N/A Substitute NO

08/22/2022 11/19/2022 Teacher 1 Pansol Integrated National High School 25439.00 N/A Substitute NO

05/18/2022 06/01/2022 Teacher 1 Padre Garcia National High School 25439.00 N/A Substitute NO

01/11/2022 03/23/2022 Teacher 1 Pansol Integrated National High School 23877.00 N/A Substitute NO

10/6/2020 12/21/2020 Teacher 1 Padre Garcia National High School 22316.00 N/A Substitute NO
Junior High School Teacher/ Program
06/01/2016 11/22/2019 Bixby Knolls Preparatory Academy 15000.00 N/A Regular NO
Coordinator
NOTHING FOLLOWS
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. NUM BER OF
(Write in full) (mm/dd/y y y y ) POSITION / NATURE OF WORK
HOUR S
From To
MOST HOLY ROSARY PARI SH - Pad re
06/03/2013 05/29/2015 N/A FULL TI ME CATECHIST
Garcia, Bat ang as
MUNICIPAL L OCAL GOVERNMENT
10/25/2010 05/13/2013 N/A SK KAGAWAD - Brgy. Pan sol
OPERATION - Padre Garcia
NOTHI NG FOLL OWS

(Co nti nu e o n sep ar ate sh eet i f n ecessar y)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
(Star t fr o m the m o st r ecen t L & D/tr ain i ng p ro gr am an d i ncl u de on l y th e r el evant L& D/trai ni n g taken fo r the l ast fi ve (5) years for Divi si on
Chi ef/Execu ti ve/Manag eri al p osi tio ns)
TITLE OF LEARNING AND DEVELOPMENT INCLUSIVE DATES OF Type o f LD
30. NUM BER OF ( M a na ge ria l/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE HOUR S S upe rvis o ry/ (Write in full)
(Write in full) From To Te c hnic a l/e tc )
Gen d er an d Devel o pm en t: Fo cu si n g o n
PA DRE GA RCIA INTEGRATED NATIONA L
Str en g th en i n g Th e CODI System i n Sch o o l s an d 06/27/2022 06/27/2022 8 HRS. T ECHNICAL
HIGH SCHOOL
Offi ces
2021 In -Ser vi ce Tr ai ni n g (INSET) fo r Ju n i o r Hig h PRIVA TE EDUCATION A SSISTA NCE
08/19/2021 08/21/2021 27 HRS. T ECHNICAL
Sch o o l Teach er COMMITTEE
PSHS-CVi sC A cad em i c Co n fer en ce o n Hu m an i ti es PHIL IPPINE SCIENCE HIGH SCHOOL -
07/08/2021 07/09/2021 18 HRS. T ECHNICAL
an d So ci al Sci en ces CENTRA L VISAYA S CA MPUS
ISO19011:2018 Gu i d an ce in A u d iti n g Man ag em en t B IX B Y K NOL L S PREPA RATORY
06/16/2021 06/16/2021 9 HRS. T ECHNICAL
System A CA DEMY
Pr o j ect A d van ci n g Sch o o l Su ccess an d In i tiati ves PHIL IPPINE NORMA L UNIVERSITY (vi a
12/12/2020 12/12/2020 10 HRS. T ECHNICAL
fo r Su stain ab l e To m o r r o w (A SSIST) ZOOM)
2019 SUMMER IN-SERVICE TRA INING FOR SENIOR
HIGH SCHOOL TEA CHER - ENSURING SHS LYCEUM OF THE PHIL IPPINES
06/07/2019 06/09/2019 30 HRS. T ECHNICAL
L EA RNERS' PREPA RATION FOR THE FOUR EX ITS UNIVERSITY-L A GUNA
OF K TO 12 CURRICUL UM
IN-SERVICE TRA INING: Co n str u ctin g Tab l e o f B IX B Y K NOL L S PREPA RATORY
06/24/2019 06/26/2019 27 HRS. T ECHNICAL
Sp ecifi cati o n an d Rub r i cs A CA DEMY
K UMPERENSIYA SA FIL IPINO 2019: A n g Hi n ah ar ap
02/14/2019 02/15/2019 18 HRS. T ECHNICAL VIB A L GROUP
n g Pag tu tu r o n g A sig n atu r an g Fil i p i n o , CPD
SEMINA R WORK SHOP ON B A SIC
UNDERSTA NDING A ND A SSESSMENT SK IL L S IN 02/12/2019 02/12/2019 9 HRS. T ECHNICAL UNIVERSITY OF A SIA A ND THE PA CIFIC
THE ENHA NCEMENT OF EX ECUTIVE FUNCTION IN
INTERFA CING B RA IN-B A SED L EA RNING WITH
TRA NSFORMATIVE TEA CHING FOR NEX TGEN 11/10/2018 11/10/2018 9 HRS. T ECHNICAL PHOENIX DEVEL OPMENT CENTER
L EA RNERS IN FIL IPINO
IN-SERVICE TRA INING: Effecti ve Cl assr o o m B IX B Y K NOL L S PREPA RATORY
06/24/2018 06/26/2018 27 HRS. T ECHNICAL
Man ag em en t Tech n iq u es A CA DEMY
B IX B Y K NOL L S PREPA RATORY
IN-SERVICE TRA INING: En g li sh Pr o fien cy 06/14/2018 06/16/2018 27 HRS. T ECHNICAL
A CA DEMY
SEMINA R WORK SHOP ON A DVA NCED PHIL OSOPY
11/11/2017 11/11/2017 9 HRS. T ECHNICAL SA N PA B L O COL L EGES
OF EDUCATION: Past, Pr esen t an d Fu tu r e o f Ph i l .
IN-SERVICE TRA INING FOR SENIOR HIGH LYCEUM OF THE PHIL IPPINES
07/26/2017 07/28/2017 27 HRS. T ECHNICAL
TEA CHERS UNIVERSITY - L A GUNA
L EA DERSHIP A ND CA REER SEMINA R: Th e Ro ad OB L ATES OF SA INT JOSEPH MA JOR
03/17/2016 03/18/2016 18 HRS. T ECHNICAL
to Teach i n g , L ead er sh ip an d Car eer Ski ll s Sem i n ar SEMINA RY
B EATA L ENT WORK SHOP: B eatal en t's 3 d ays A cti n g
02/26/2016 02/28/2016 27 HRS. T ECHNICAL K OL EHIYO NG L UNGSOD NG L IPA
Wo r ksh o p
K TO 12 AT MAKABAGONG EST RAT EHIYA
08/26/2013 08/28/2013 27 HRS. T ECHNICAL K OL EHIYO NG L UNGSOD NG L IPA
T UNGO SA MABISANG PAGTUTURO NG
17TH PROVINCIAL JAMBORET TE; SCOUTS: B OY SCOUT OF THE PHIL IPPINES -
02/18/2009 02/22/2009 45 HRS. T ECHNICAL
Creating a Better World B ATA NGA S COUNCIL

NOTHING FOLLOWS

(Con ti nu e o n separ ate sheet if necessar y)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 33. ASSOCIATION/ORGANIZATION
(Write in full)
(Write in full)
DEPED SCHOOLS INVIT ED JUDGE - MR. AND MS. UNITED DIL G-PA DRE GA RCIA SA NGGUNIA NG
DANCI NG
NAT IONS/ SCIENCE MONT H CULMINAT ING ACT IVIT Y K A B ATA A N COUNCIL OR, B RGY. PA NSOL
LEADERSHIP AND CAREER SEMINAR - OVER ALL B SP B ATA NGA S PROVINCE COUNCIL -
SINGI NG
MODERAT OR EA GL E SCOUT
34. Are you related by consanguinity or affinity to the appointing or recommending authority, or
chief of bureau or office or to the person who has immediate supervision over you in the
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? End of Contract

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 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 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
a following
Are you aitems:
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
PANSOL, PADRE GARCIA, the last 6 months
RYAN DE L EON 9271771429 3.5 cm. X 4.5 cm
BATANGAS (passport size)
PANSOL, PADRE GARCIA,
JENNY VILELA 9208607856 With f ull and handwritten
BATANGAS name tag and signature ov er
PANSOL, PADRE GARCIA, printed name
SHAUN MARK TAPALLA 9476995212
BATANGAS Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct or photocopied picture
is not acceptable
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 PHOTO
filing of administrative/criminal case/s against me.

Gov ernment Issued ID (i.e .P a s s po rt, GS IS , S S S , P R C , Drive r's

Lic e ns e , e tc .) PLEASE INDICATE ID Number
Gov ernment Issued ID: PRC-ID

ID/License/Passport No.: 1721697

Signature (Sign inside the box )

Date/Place of Issuance: L UCENA