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 JUARBAL
NAME EXTENSION (JR., SR)
FIRST NAME MANELYN

MIDDLE NAME TADEM

3. DATE OF BIRTH
(mm/dd/yyyy) 7/18/1992 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH Pague-Pague, Camagong, Tago, Surigao del Sur 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 Lower Mambago
Widowed Separated House/Block/Lot No. Street
Dayo-an
Other/s:
Subdivision/Village Barangay
Tago, Surigao Del Sur
7. HEIGHT (m) 1.63m
City/Municipality Province
8. WEIGHT (kg) 80 kg ZIP CODE

18. PERMANENT ADDRESS Purok Lower Mambago

9. BLOOD TYPE A+
House/Block/Lot No. Street
Dayo-an
10. GSIS ID NO. N/A
Subdivision/Village Barangay
Tago, Suriago Del Sur
11. PAG-IBIG ID NO. 121305672904
City/Municipality Province

12. PHILHEALTH NO. 18-200966441-7 ZIP CODE

13. SSS NO. 08-2898379-4 19. TELEPHONE NO. None

14. TIN NO. 611-566-740-00000 20. MOBILE NO. 09073493885

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) mtjuarbal18@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME JUARBAL 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME WILLIAM LYNDHON T. JUARBAL 6/26/2013

MIDDLE NAME IROY LIAM ANDREI T. JUARBAL 1/17/2018

OCCUPATION FARMER JAM KYLE T. JUARBAL 3/5/2019

EMPLOYER/BUSINESS NAME N/A XIAN ALEXI T. JUARBAL 10/17/2020

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME TADEM

NAME EXTENSION (JR., SR)
FIRST NAME NANECITO

MIDDLE NAME SAMONTINA

25. MOTHER'S MAIDEN NAME

SURNAME LLAMAS

FIRST NAME ELINDA

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

ELEMENTARY Tabon-Tabon Elementary School ELEMENTARY 1999 2005 2005 Valedictorian

SECONDARY
VOCATIONAL / Gamut National High School SECONDARY 2005 2009 2009

N/A N/A N/A N/A N/A None

TRADE
COURSE 2011 Tulong Dunong
COLLEGE SURIGAO DEL SUR STATE UNIVERSITY Bachelor of Science in Mathematics 2018 2018 Scholarship

GRADUATE STUDIES N/A N/A N/A N/A N/A None

(Continue on separate sheet if necessary)

SIGNATURE DATE
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 (LET) 0.8260 OCTOBER 2, 2022 BUTUAN 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
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)
MATHEMATICS TEACHER
Nov-21 PRESENT GAMUT TEKNIA SCHOOL, INC. 5000-6000 N/A N/A
(GRADE4-9) CONTRACTUAL
 (Continue on separate sheet if necessary)

SIGNATURE DATE
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

(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

REVISITING
COMPUTATION OF MPS,
MID-YEAR IN-SERVICE TRAINING 7/2/2023 9/2/2023 30.0 ITEM ANALYSIS AND MARY JUNNETH E. LLESIS
MPL

MODULAR TRAINING PROGRAM in PERSONAL COMPUTER OPERATION 4/12/2023 01/21/2023 MARCELINO C. ANINO

(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 in
(Write in full)
full)
PAFTE(PHILIPPINE ASSOCIATION for
Computer Literate
TEACHER EDUCATION)
Analytical Thinking Skills

Reading different of books

Searching/Surfing

(Continue on separate sheet if necessary)

SIGNATURE DATE
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:
________________________________
________________________________
YES ✘ NO
b. Have you been criminally charged before any court?
If YES, give details:
________________________________
Date Filed:
________________________________
Status of Case/s:
YES ✘ NO
36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation
by any court or tribunal?
If YES, give details:
________________________________
YES NO
________________________________
✘

37. Have you ever been separated from the service in any of the following modes: resignation,
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? ________________________________
YES ✘ NO
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? YES If YES, give details:
✘ NO
b. Have you resigned from the government service during the three (3)-month period before the last
election to promote/actively campaign for a national or local candidate? YES If YES, give details:
✘ NO
39. Have you acquired the status of an immigrant or permanent resident of another country?
If YES, give details (country):

40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA YES ✘ NO
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?
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 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
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:

ID/License/Passport No.:
Signature (Sign inside the box)
JANUARY 07,2020
Date/Place of Issuance:
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