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 Purisima
NAME EXTENSION (JR., SR)
FIRST NAME Mary anne

MIDDLE NAME Teoxon

3. DATE OF BIRTH
(mm/dd/yyyy) January 13,1988 16. CITIZENSHIP
✘ Filipino Dual Citizenship

by birth by naturalization
4. PLACE OF BIRTH Guijalo Caramoan Camarines Sur If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX
Male ✘ Female
17. RESIDENTIAL ADDRESS 0106 Buenviaje st.
6 CIVIL STATUS Single
✘ Married House/Block/Lot No. Street
Widowed Separated N/A Guijalo
Other/s:
Subdivision/Village Barangay
Caramoan Camarines Sur
7. HEIGHT (m) 5'4"
City/Municipality Province
8. WEIGHT (kg) 80
18. PERMANENT ADDRESS 0106 Buenviaje st.
9. BLOOD TYPE O
House/Block/Lot No. Street
N/A Guijalo
10. GSIS ID NO. N/A
Subdivision/Village Barangay
Caramoan Camarines Sur
11. PAG-IBIG ID NO. 121112848699
City/Municipality Province

12. PHILHEALTH NO. 02-026104995-4 ZIP CODE 4429

13. SSS NO. 0111-7536051-9 19. TELEPHONE NO. N/A

14. TIN NO. 944-150-241 20. MOBILE NO. 09304048564

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) mheannepurisima@gmail.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) Mar Manuel P. Israel
FIRST NAME N/A December 5, 2006

MIDDLE NAME N/A Mauie Clark P. Israel April 4, 2012

OCCUPATION N/A Luth Rexadelmar P. Israel May 29, 2015

EMPLOYER/BUSINESS NAME N/a

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME Purisima

NAME EXTENSION (JR., SR)
FIRST NAME Recardo

MIDDLE NAME Bien

25. MOTHER'S MAIDEN NAME Parañal

SURNAME Purisima

FIRST NAME Adelfa

MIDDLE NAME Teoxon (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 Guijalo Elementary School Elementary 5/6/1996 8/4/2001 2001 3rd honor

SECONDARY /
VOCATIONAL Guijalo National High School High School 4/6/2001 03/31/2005 2005 With Hoonor

N/A N/A N/A

TRADE
Bachelor of Science in Hotel and Restaurant
COURSE
COLLEGE Partido State University
Management
6/6/2008 10/4/2015 2015 N/A

GRADUATE STUDIES Caramoan Community College Certificate for Professional Education 5/6/2018 2/4/2019 2019 N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE April 8,2023

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

Board for Professional Teacher 79.4 4/10/2022 Legaspi City 1986797 01/13/2026

(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)

07/15/2019 04/15/2020 Registrar Clerk Caramoan Community College 6000.00 CONRACTUAL Y

10/16/2020 12/31/2021 Contact Tracer DILG Region V and LGU Caramoan 18723.00 J.O Y
 (Continue on separate sheet if necessary)

SIGNATURE DATE April 8,2023

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

TESDA NCII CSS(Computer System Services) 01/15/2023 01/27/2023 CSS

IN-SET( In Service Training

(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)

Playing Volleyball and Basketball Best Setter N/A

 (Continue on separate sheet if necessary)

SIGNATURE DATE April 8,2023

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

✘
b. within the fourth degree (for Local Government Unit - Career Employees)? YES

✘
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
by any court or tribunal? YES ✘ NO
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
GONZALO I. TORIO GOA,CARAMOAN, CAMARINES SUR 9387960042 3.5 cm. X 4.5 cm
(passport size)

LOURDES B. MENDOZA TAWOG, CARAMOAN, CAMARINES SUR 9569961361 With full and handwritten
name tag and signature over
printed name
CHING DEL CASTILLO TAWOG, CARAMOAN, CAMARINES SUR 9481019740
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 PHOTO
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: 944-150-241

ID/License/Passport No.: 1986797

Signature (Sign inside the box)
04/08/2023
Date/Place of Issuance: Robinson Naga
Date/Place of Issuance: Robinson Naga
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