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 PADILLA
NAME EXTENSION (JR., SR)
FIRST NAME JUBERT

MIDDLE NAME LOZANO

3. DATE OF BIRTH
(mm/dd/yyyy) 11/2/1987 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH ANGELES CITY, PAMPANGA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female
✘ Single Married 17. RESIDENTIAL ADDRESS
6 CIVIL STATUS
Widowe Separated House/Block/Lot No. Street
d PAYOCPOC NORTE ESTE
Other/s: Subdivision/Village Barangay
BAUANG LA UNION
7. HEIGHT (m) 5'4"
City/Municipality Province
8. WEIGHT (kg) 150 ZIP CODE

18. PERMANENT ADDRESS No. 13 Purok V

9. BLOOD TYPE A+
House/Block/Lot No. Street
SAN MARCOS
10. GSIS ID NO.
Subdivision/Village Barangay
AGOO LA UNION
11. PAG-IBIG ID NO. 01-015956891-1
City/Municipality Province

12. PHILHEALTH NO. 05-050125125-6 ZIP CODE 2504

13. SSS NO. 01-1874394-5 19. TELEPHONE NO.

14. TIN NO. 261-837-596 20. MOBILE NO. 0927-427-9047

15. AGENCY EMPLOYEE NO. 4213820 21. E-MAIL ADDRESS (if any) jubpad@yahoo.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)
NAME EXTENSION (JR., SR) N/A
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME PADILLA 6/30/1952

NAME EXTENSION (JR., SR)
FIRST NAME FAUSTINO

MIDDLE NAME RIMORIN

25. MOTHER'S MAIDEN NAME LANSANGAN 6/19/1963

SURNAME PADILLA

FIRST NAME JULIETA

MIDDLE NAME LOZANO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY SAN JOSE SAN JOAQUIN ELEMENTARY SCHOOL ELEMENTARY 6/1/1994 4/22/2000 2000
SECONDARY
VOCATIONAL / PRES. ELPIDIO QUIRINO NATIONAL HIGH SCHOOL HIGH SCHOOL 6/2/2000 4/23/2004 2004

AGOO COMPUTER COLLEGE COMPUTER HARDWARE SERVICING NC II 11/2/2009 11/30/2009 2009 PGS SCHOLAR
TRADE 6/2/2004 3/30/2008
COURSE
COLLEGE
DON MARIANO MARCOS MEMORIAL STATE 1) BS COMPUTER SCIENCE 2) 1) 179 UNITS 2) 28 1) 2008
UNIVERSITY EDUCATIONAL UNITS
6/13/2011 03/28/2012
UNITS 2) 2012

GRADUATE STUDIES COLEGIO DE DAGUPAN MASTER IN INFORMATION TECHNOLOGY 5/3/2013 3/30/2015 42 UNITS 2015 CHED SCHOLAR

(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
LORMA COLLEGES / PANGASINAN TMC170155010 JUNE 27,
TRAINER'S METHODOLOGY LEVEL 1 COMPETENT 10/21/2016
TECHNOLOGICAL INSTITUTE 00080 2022

(TESDA) CERTIFIED COMPUTER SYSTEMS 1601550201772

COMPETENT 04/29/2016 BRIGHT SCHOOL URDANETA CITY
SERVICING NC II 1
(TESDA) CERTIFIED VISUAL GRAPHIC DESIGN NC 1401030300248
COMPETENT 07/18/2014 LORMA COLLEGES
III 8
NOVEMBER
PROFESSIONAL TEACHER (LET PASSER) PASSED 12/05/2012 MABINI ELEMENTARY SCHOOL, BAGUIO CITY 1148002 02, 2023

(TESDA) COMPETENT IN COMPUTER HARDWARE OCTOBER

COMPETENT 10/01/2009 AGOO COMPUTER COLLEGE 090103027907
SERVICING NC II 2014

(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)
DON EULOGIO DE GUZMAN MEMORIAL
06/05/2017 PRESENT TEACHER III PhP 25,232 SG-13 PRESENT Y
NATIONAL HIGH SCHOOL
PHILIPPINE COLLEGE OF
06/16/2014 10/01/2014 PART TIME I.T. INSTRUCTOR PhP 2,000 END OF TERM N
NORTHWESTERN LUZON
AGOO MONTESSORI LEARNING CENTER END OF
06/01/2014 03/31/2015 FULL TIME COMPUTER TEACHER PhP 8,000 N
AND HIGH SCHOOL, INC. CONTRACT
SOUTH ILOCANDIA COLLEGE OF ARTS END OF
06/11/2012 03/01/2017 DEAN / PROGRAM HEAD PhP 10,000 N
AND TECHNOLOGY CONTRACT
END OF
02/21/2011 04/13/2011 CUSTOMER SERVICE PROVIDER PICTURE CITY INTERNATIONAL, INC. PhP 7,000 CONTRACT
N

05/03/2008 07/26/2008 ENCODER UNIVERSAL LEAF PHILIPPINES, INC. PhP 6,292 LAID OFF N

(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

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 ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

REGIONAL MASS TRAINING OF TEACHERS FOR GRADE 12 ON COMMON TOPICS 10/10/2017 10/13/2017 32 HOURS EDUCATIONAL DEPED - REGION I

DIVISION TEACHER INDUCTION PROGRAM BATCH 2 10/02/2017 10/04/2017 24 HOURS EDUCATIONAL DEPED - LA UNION SCHOOLS DIVISION
UP SYSTEM INFORMATION TECHNOLOGY
14TH YOUTH CONGRESS ON INFORMATION TECHNOLOGY 09/27/2016 09/27/2016 8 HOURS TECHNICAL
FOUNDATION
ASSESSMENT AND VALIDATION CONFERENCE: TOWARDS A MORE INNOVATIVE
02/12/2016 02/12/2016 8 HOURS EDUCATIONAL COMMISION ON HIGHER EDUCATION
PHILIPPINE HIGHER EDUCATION
DIVISION MASS TRAINING OF GRADE 10 TLE TEACHERS ON K TO 12 BASIC
06/05/2015 06/06/2015 16 HOURS EDUCATIONAL DEPARTMENT OF EDUCATION
EDUCATION PROGRAM
DESIGNING AND USING STANDARDS-BASED ASSESSMENT AND RUBRICS FOR
03/20/2015 03/21/2015 16 HOURS EDUCATIONAL PHOENIX PUBLISHING HOUSE, INC.
ARALING PANLIPUNAN
ASSOCIATION OF PRIVATE SCHOOLS,
APSCU 1: PREPPIN FOR K-12 EDUCATIONAL REFORMS AD INITIATIVES 01/22/2015 01/22/2015 8 HOURS EDUCATIONAL
COLLEGES, AND UNIVERSITIES
INSTRUCTIONAL LEADER'S GUIDE TO TRANSFORMATIVE ASSESSMENT 01/19/2015 01/20/2015 16 HOURS EDUCATIONAL REX PUBLISHING

TECHTRACKS: INNOVATION BEYOND IMAGINATION 08/22/2014 08/22/2014 8 HOURS TECHNICAL LORMA COLLEGES
PHILIPPINE SOCIETY OF INFORMATION
EMERGING ICT FOR CITIZENS' VEILLANCE 08/01/2014 08/02/2014 16 HOURS TECHNICAL
TECHNOLOGY
eLEARNING GAME CHANGERS: FACING THE CHALLENGES OF ASEAN 2015 AND
06/28/2014 06/28/2014 8 HOURS TECHNICAL PHILIPPINE eLEARNING SOCIETY
K TO 12
REGION I GASTPE GUIDELINE ORIENTATION & FAPE ONLINE ENCODING
05/22/2014 05/22/2014 8 HOURS EDUCATIONAL DEPARTMENT OF EDUCATION
SYSTEM TRAINING
MAKING IT WORKS! HIGHER EDUCATION FOR STUDENTS WITH DISABILITIES 02/13/2014 02/14/2014 16 HOURS EDUCATIONAL RESOURCES FOR THE BLIND, INC.

COMPUTER HARDWARE SERVICING 06/19/2009 09/24/2009 356 HOURS TECHNICAL AGOO COMPUTER COLLEGE
WINGS INSTITUTE OF GLOBAL CAREERS,
CONTACT CENTER FOUNDATION TRAINING 03/31/2008 04/16/2008 144 HOURS TECHNICAL
INC.

(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)

GRAPHIC DESIGNING TRAINER'S METHODOLOGY LEVEL 1 BOARD FOR PROFESSIONAL TEACHERS

PHILIPPINE SOCIETY OF INFORMATION
PHOTO EDITING CERTIFIED COMPUTER SYSTEMS SERVICING
TECHNOLOGY
NETWORK CONFIGURATION CERTIFIED VISUAL GRAPHIC DESIGN PHILIPPINE eLEARNING SOCIETY
COMPUTER HARDWARE AND SOFTWARE COUNCIL OF INFORMATION TECHNOLOGY EDUCATION
CERTIFIED COMPUTER HARDWARE SERVICING
MAINTENANCE AND INSTALLATION DEANS AND HEADS - REGION 01

WEB PAGE DESIGNING ORACLE ACADEMY

COMPUTER PROGRAMMING

(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:
________________________________
________________________________
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 NO
YES ✘
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: END OF TERM OR CONTRACT IN
out (abolition) in the public or private sector? PRIVATE SECTORS
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
DR. EMELYN C. HOBAYAN DEPED LA UNION - DEGMNHS 619-3288 3.5 cm. X 4.5 cm
(passport size)

JONALYN L. REOLIQUIO SAN EUGENIO, ARINGAY, LA UNION 714-0213 With full and handwritten
name tag and signature over
printed name
RESURRECCION S. ORENCIA AGOO MONTESSORI LEARNING CENTER 0920-9068-339
Computer generated
or photocopied picture
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete 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.: 1148002

Signature (Sign inside the box)

Date/Place of Issuance: December 05, 2012

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