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 TIGALLO
NAME EXTENSION (JR., SR)
FIRST NAME CLARO

MIDDLE NAME ABAY

3. DATE OF BIRTH
(mm/dd/yyyy)
12/16/1979 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH KABANKALAN, NEGROS OCCIDENTAL If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS Prk. Nami-Nami

Widowed House/Block/Lot No. Street
Separate
Brgy. Sum-ag
Other/s: d
Subdivision/Village Barangay

7. HEIGHT (m) 1.50 M BACOLOD CITY NEGROS OCCIDENTAL

City/Municipality Province
8. WEIGHT (kg) 95 kg ZIP CODE 6100

9. BLOOD TYPE O
18. PERMANENT ADDRESS Prk. Nami-Nami
House/Block/Lot No. Street

10. GSIS ID NO. 006-0035-5095-9 Brgy. Sum-ag

Subdivision/Village Barangay
BACOLOD CITY NEGROS OCCIDENTAL
11. PAG-IBIG ID NO. 1590-0050-2618
City/Municipality Province

12. PHILHEALTH NO. 11-000119849-1 ZIP CODE 6100

13. SSS NO. none 19. TELEPHONE NO.

14. TIN NO. 927-245-674 20. MOBILE NO. 9479472516

15. AGENCY EMPLOYEE NO. 2915 21. E-MAIL ADDRESS (if any)

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME ITURRIAGA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME CARMELA

NAME EXTENSION (JR., SR) NICOLE GRACE I. TIGALLO 2/18/2006

MIDDLE NAME DAGASA-AN JOHN KEVIN I. TIGALLO 12/21/2007

OCCUPATION TEACHER AMELIA CASSANDRA I. TIGALLO 4/27/2015

EMPLOYER/BUSINESS NAME DEP. ED

BUSINESS ADDRESS ISABELA, NEGROS OCCIDENTAL

TELEPHONE NO.

24. FATHER'S SURNAME TIGALLO

NAME EXTENSION (JR., SR)
FIRST NAME ROGELIO

MIDDLE NAME LEGORE

25. MOTHER'S MAIDEN NAME DIAZ

SURNAME TIGALLO

FIRST NAME CLARA

MIDDLE NAME ABAY (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY SUM- AG ELEMENTARY SCHOOL 3/31/1992 1992

SECONDARY
VOCATIONAL / SUM-AG NATIONAL HIGH SCHOOL 6/14/1992 3/31/1997 1997

TRADE
COURSE
COLLEGE UNIVERSITY OF NEGROS OCCIDENTAL- RECOLETOS 6/2/1997 3/31/2001 2001

GRADUATE STUDIES STI-WEST NEGROS COLLEGE 4/8/2016 PRESENT

(Continue on separate sheet if necessary)

SIGNATURE DATE 10/ 11/2918 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

LET EXAMINATION 79.2 Aug. 2001 ILOILO CITY

(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
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To
(Y/ N)

7/15/2002 3/31/2003 Teacher 1 NESCA 9939.00 Substitute yes

6/22/2004 8/31/2004 Teacher 1 Bacolod City NHS 9939.00 Substitute yes

10-04--04 12/2/2004 Teacher 1 Bacolod City NHS 9939.00 Substitute yes

1/16/2006 6/30/2007 Teacher 1 Bata HNS 9939.00 Regular Permanent yes

7/1/2007 6/30/2008 Teacher 1 Bata HNS 10933.00 Regular Permanent yes

7/1/2008 1/16/2009 Teacher 1 Bata HNS 12023.00 Regular Permanent yes

Regular
1/17/2009 6/30/2009 Teacher 1 Bata HNS 12328.00 yes
Permanent
Regular
7/1/2009 6/23/2010 Teacher 1 Bata HNS 14483.00 yes
Permanent
Regular
6/24/2010 5/31/2011 Teacher 1 Bata HNS 15900.00 yes
Permanent
Regular
6/1/2011 12/31/2011 Teacher 1 Bata HNS 17318.00 yes
Permanent
Regular
1/1/2012 1/16/2012 Teacher 1 Bata HNS 17318.00 yes
Permanent
Regular
1/17/2012 5/31/2012 Teacher 1 Bata HNS 17540.00 yes
Permanent
Regular
6/1/2012 1/16/2015 Teacher 1 Bata HNS 18922.00 yes
Permanent
Regular
1/17/2015 12/31/2015 Teacher 1 Bata HNS 19111.00 yes
Permanent
Regular
1/1/2016 12/31/2016 Teacher 1 Bata HNS 19709.00 yes
Permanent
Regular
1/1/2017 Present Teacher 1 Sum-ag NHS 20326.00 yes
Permanent

(Continue on separate sheet if necessary)

SIGNATURE DATE 10/11/2018 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

NONE

NONE

(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) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

PVF NATIONAL VOLLEYBALL COACHES COURSE LEVEL 1 8/4/2017 8/8/2017 50 hours PVF DEP-ED/ USLS

SPORT MANAGEMENT TRAINING 2/10/2017 2/12/2017 24 hours DEP-ED

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

OFFICIATING PHIL. VOLLEYBALL ASSOCIATION

SINGING

DANCING

PLAYING VOLLEYBALL, BASKETBALL

LAWN TENNIS, BADMINTON, TABLE TENNIS

(Continue on separate sheet if necessary)

SIGNATURE DATE 10/11/2018 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? ________________________________
________________________________
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
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 complete or photocopied picture
is not acceptable
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 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

ID/License/Passport No.: 729717

Signature (Sign inside the box)
10/11/2018
Date/Place of Issuance: 06/22/2017 ILOILO 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