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 NOLLA

FIRST NAME SHENNA NAME EXTENSION (JR., SR) N/A

MIDDLE NAME HABAC

3. DATE OF BIRTH
(mm/dd/yyyy)
ARIL 10, 1995 16. CITIZENSHIP

4. PLACE OF BIRTH TAYTAY PALAWAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX FEMALE FILIPINO
17. RESIDENTIAL ADDRESS
6 CIVIL STATUS MARRIED
House/Block/Lot No. Street
SITIO MALAPAJO POBLACION
Subdivision/Village Barangay
7. HEIGHT (m) 5'5 TAYTAY PALAWAN
City/Municipality Province
8. WEIGHT (kg) 70 ZIP CODE 5312
18. PERMANENT ADDRESS
9. BLOOD TYPE O+
House/Block/Lot No. Street

10. GSIS ID NO. N/A SITIO MALAPAJO POBLACION

Subdivision/Village Barangay
TAYTAY PALAWAN
11. PAG-IBIG ID NO. N/A
City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 5312

13. SSS NO. 04-3877874-2 19. TELEPHONE NO. N/A

14. TIN NO. 492-503-023 20. MOBILE NO. 09555196492

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) shennahabac30@gmail.com

II. FAMILY BACKGROUND

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

FIRST NAME ERICKSON NAME EXTENSION (JR., SR) N/A ELLAH SYRIEN HABAC NOLLA 1/12/2013

MIDDLE NAME LOPEZ ERICKSON JR. HABAC NOLLA 8/31/2016

OCCUPATION SEAWEEDS FARMER Nothing Follows

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. 09702603842

24. FATHER'S SURNAME HABAC

FIRST NAME RONNEL NAME EXTENSION (JR., SR) N/A

MIDDLE NAME DURANA

25. MOTHER'S MAIDEN NAME

SURNAME MARAVILLA

FIRST NAME LOURDES

MIDDLE NAME LAURENTE (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
(Write in full) HONORS
full) (if not graduated) RECEIVED
From To

ELEMENTARY BUSY BEES ELEMENTARY SCHOOL ELEMENTARY 2001 2006 GRADUATED 2006 N/A

CENTRAL TAYTAY NATIONAL HIGH

SECONDARY /
VOCATIONAL HIGH SCHOOL 2013 2014 GRADUATED 2013 N/A
SCHOOL (ALS)
NORTHERN PALAWAN TECHNOLOGICAL
EVENTS MANAGEMENT NC II 2018 2019 GRADUATED 2014 N/A
INSTITUTE INC.
TRADE
PALAWAN STATE UNIVERSITY TAYTAY- BACHELOR OF SCIENCE IN BUSINESS
COURSE
COLLEGE 2018 2022 GRADUATED 2022 N/A
CAMPUS ADMINISTRATION

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A

(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

N/A N/A N/A N/A N/A N/A

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.
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)

7/1/2022 9/30/2022 ADMINISTRATIVE AIDE III GOVERNOR'S OFFICE 8854.00 N/A N/A N/A

10/3/2022 12/31/2022 ADMINISTRATIVE AIDE III GOVERNOR'S OFFICE 8854.00 N/A N/A N/A

1/16/2023 6/30/2023 ADMINISTRATIVE AIDE III GOVERNOR'S OFFICE 8854.00 N/A N/A N/A

Nothing Follows Nothing Follows

(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 N/A N/A N/A N/A

Nothing Follows

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
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) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To

N/A N/A N/A N/A N/A N/A

Nothing Follows

(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)

COMPREHENSIVE COMMUNICATION SKILLS N/A N/A

SOFTWARE SKILLS (MS Word, MS Power Point
Nothing Follows Nothing Follows
and MS Excel)
Nothing Follows

(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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
________________________________

35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court?
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 or tribunal?
If YES, give details:
________________________________
________________________________
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 If YES, give details:
phased 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 Barangay election)?
If YES, give details:
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? If YES, give details:
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 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?
If YES, please specify:
b. Are you a person with disability?
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
MARIANO A. DELOS SANTOS TAYTAY, PALAWAN 09177712425 (passport size)

With full and handwritten

RUBELYN M. SONGSONG TAYTAY, PALAWAN 09074963184 name tag and signature over
printed name

MARIA SOCORRO CECIL ACUPAN TAYTAY, PALAWAN 09688524259 Computer generated

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 PHOTO
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: TIN ID

ID/License/Passport No.: 492 503 023 000 Signature (Sign inside the box)

Date/Place of Issuance: MARCH 1, 2019 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