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 PAGULAYAN
NAME EXTENSION (JR., SR) N/A
FIRST NAME KAREN
MIDDLE NAME BAQUIRAN
3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 05/09/1979 ✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH TUGUEGARAO CITY, CAGAYAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS 6-B MAAYUSIN
Widowed Separated House/Block/Lot No. Street

Other/s:
N/A SAN VICENTE DILIMAN
Subdivision/Village Barangay
7. HEIGHT (m) 1.524m QUEZON CITY METRO MANILA
City/Municipality Province
8. WEIGHT (kg) 55kg ZIP CODE 1101

9. BLOOD TYPE O
18. PERMANENT ADDRESS 18 ADDUCUL
House/Block/Lot No. Street
10. GSIS ID NO. 006-0049-8160-8 N/A CATAGGAMAN NUEVO
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 107002098861 TUGUEGARAO CITY CAGAYAN

City/Municipality Province

12. PHILHEALTH NO. 03-000224497-3 ZIP CODE 3500

13. SSS NO. N/A 19. TELEPHONE NO. N/A

14. TIN NO. 246-101-596-000 20. MOBILE NO. 09183571973

15. AGENCY EMPLOYEE NO. 4265560 21. E-MAIL ADDRESS (if any) karen.pagulayan@deped.gov.ph
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)

FIRST NAME N/A N/A N/A N/A
MIDDLE NAME N/A
OCCUPATION N/A
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME PAGULAYAN (DECEASED)
NAME EXTENSION (JR., SR)
FIRST NAME SIXTO SR.

MIDDLE NAME GUZMAN

25. MOTHER'S MAIDEN NAME

SURNAME BAQUIRAN (DECEASED)

FIRST NAME ADORACION
MIDDLE NAME TABAO (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 CATAGGAMAN ELEMENTARY SCHOOL PRIMARY EDUCATION 1986 1992 GRADUATED 1992 N/A

CAGAYAN NATIONAL HIGH SCHOOL

SECONDARY /
VOCATIONAL HIGH SCHOOL 1992 1996 GRADUATED 1996 N/A
(CATAGGAMAN ANNEX)

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

TRADE
ST. PAUL UNIVERSITY (TUGUEGARAO BACHELOR OF ELEMENTARY
COURSE
COLLEGE 1996 2000 GRADUATED 2000 N/A
CITY) SCHOOL
MASTER OF ARTS IN EDUCATION MAJOR IN SUMMER
GRADUATE STUDIES LUNA COLLEGES EDUCATIONAL MANAGEMENT 2016 2018
39 UNITS 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

LICENSURE EXAMINATION FOR TEACHERS 75.00 08/27/2000 TUGUEGARAO CITY 0666531 05/09/2024

(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)
DEPARTMENT OF EDUCATION/SCHOOLS DIVISION OFFICE, QUEZON
01/01/2021 Present TEACHER I CITY/PINYAHAN ELEMENTARY SCHOOL 24,742.00 11-4 PERMANENT Y
DEPARTMENT OF EDUCATION/SCHOOLS DIVISION OFFICE, QUEZON
01/01/2020 12/31/2020 TEACHER I CITY/PINYAHAN ELEMENTARY SCHOOL 23,181.00 11-4 PERMANENT Y
DEPARTMENT OF EDUCATION/SCHOOLS DIVISION OFFICE, QUEZON
01/01/2019 12/31/2019 TEACHER I CITY/PINYAHAN ELEMENTARY SCHOOL 21,619.00 11-4 PERMANENT Y
DEPARTMENT OF EDUCATION/SCHOOLS DIVISION OFFICE, QUEZON
01/01/2018 12/31/2018 TEACHER I CITY/PINYAHAN ELEMENTARY SCHOOL 21,327.00 11-3 PERMANENT Y
DEPARTMENT OF EDUCATION/SCHOOLS DIVISION OFFICE, QUEZON
01/01/2017 12/31/2017 TEACHER I CITY/PINYAHAN ELEMENTARY SCHOOL 20,698.00 11-3 PERMANENT Y
DEPARTMENT OF EDUCATION/SCHOOLS DIVISION OFFICE, QUEZON REGULAR/
02/13/2016 12/31/2016 TEACHER I CITY/PINYAHAN ELEMENTARY SCHOOL 20,088.00 11-3 Y
PERMANENT
DEPARTMENT OF EDUCATION/SCHOOLS DIVISION OFFICE, QUEZON REGULAR/
01/01/2016 02/12/2016 TEACHER I CITY/PINYAHAN ELEMENTARY SCHOOL 19,496.00 11-3 Y
PERMANENT
DEPARTMENT OF EDUCATION/SCHOOLS DIVISION OFFICE, QUEZON REGULAR/
02/13/2013 12/31/2015 TEACHER I CITY/PINYAHAN ELEMENTARY SCHOOL 18,922.00 11-3 Y
PERMANENT
DEPARTMENT OF EDUCATION/SCHOOLS DIVISION OFFICE, QUEZON REGULAR/
06/01/2012 02/12/2013 TEACHER I CITY/PINYAHAN ELEMENTARY SCHOOL 18,735.00 11-2 Y
PERMANENT
DEPARTMENT OF EDUCATION/SCHOOLS DIVISION OFFICE, QUEZON REGULAR/
06/01/2011 05/31/2012 TEACHER I CITY/PINYAHAN ELEMENTARY SCHOOL 17,318.00 11-2 Y
PERMANENT
DEPARTMENT OF EDUCATION/SCHOOLS DIVISION OFFICE, QUEZON REGULAR/
06/24/2010 05/31/2011 TEACHER I CITY/PINYAHAN ELEMENTARY SCHOOL 15,649.00 11-2 Y
PERMANENT
DEPARTMENT OF EDUCATION/SCHOOLS DIVISION OFFICE, QUEZON REGULAR/
02/13/2010 06/23/2010 TEACHER I CITY/PINYAHAN ELEMENTARY SCHOOL 14,483.00 11-2 Y
PERMANENT
DEPARTMENT OF EDUCATION/SCHOOLS DIVISION OFFICE, QUEZON REGULAR/
07/01/2009 02/12/2010 TEACHER I CITY/PINYAHAN ELEMENTARY SCHOOL 14,198.00 11-1 Y
PERMANENT
DEPARTMENT OF EDUCATION/SCHOOLS DIVISION OFFICE, QUEZON REGULAR/
07/01/2008 06/30/2009 TEACHER I CITY/PINYAHAN ELEMENTARY SCHOOL 12,026.00 10-1 Y
PERMANENT
DEPARTMENT OF EDUCATION/SCHOOLS DIVISION OFFICE, QUEZON REGULAR/
07/01/2007 06/30/2008 TEACHER I CITY/PINYAHAN ELEMENTARY SCHOOL 10,933.00 10-1 Y
PERMANENT
DEPARTMENT OF EDUCATION/SCHOOLS DIVISION OFFICE, QUEZON REGULAR/
02/13/2007 06/30/2007 TEACHER I CITY/PINYAHAN ELEMENTARY SCHOOL 9,939.00 10-1 Y
PERMANENT
DEPARTMENT OF EDUCATION/SCHOOLS DIVISION OFFICE, QUEZON REGULAR/
01/04/2007 02/12/2007 TEACHER I CITY/PINYAHAN ELEMENTARY SCHOOL 9,939.00 10-1 Y
SUBSTITUTE
DEPARTMENT OF EDUCATION/SCHOOLS DIVISION OFFICE, QUEZON REGULAR/
06/28/2006 12/22/2006 TEACHER I CITY/SAN VICENTE ELEMENTARY SCHOOL 9939.00 10-1 Y
SUBSTITUTE
 (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

(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
TECHNICAL/
THEORY OF CONSTRAINTS (TOCfe FOR EDUKASYON SA PAGPAPAHALAGA
ELEMENTARY TEACHERS)
06/28/2021 06/30/2021 6 EDUCATIONAL SCHOOLS DIVISION OFFICE, QUEZON CITY
TECHNICAL/
DEPARTMENT OF EDUCATION IN-SERVICE TRAINING 03/15/2021 03/19/2021 32 EDUCATIONAL DEPARTMENT OF EDUCATION
TECHNICAL/
IN-SERVICE TRAINING 12/14/2020 12/18/2020 32 EDUCATIONAL PINYAHAN ELEMENTARY SCHOOL
TECHNICAL/
INFORMATION COMMUNICATION AND TECHNOLOGIES GOOGLE SUITE EDUCATION
SCHOOL-BASED
05/27/2020 05/31/2020 32 EDUCATIONAL PINYAHAN ELEMENTARY SCHOOL

(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)
 EDITING N/A N/A

SINGING

COOKING

(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 ✘

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

If YES, give details:

________________________________
N/A

35. a. Have you ever been found guilty of any administrative offense? YES ✘ NO
If YES, give details:
________________________________
N/A
________________________________
b. Have you been criminally charged before any court? YES ✘ NO
If YES, give details:
________________________________
Date Filed: N/A
________________________________
Status of Case/s: N/A

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:
________________________________
N/A
________________________________
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? ________________________________
N/A
________________________________
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: N/A

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: N/A
39. Have you acquired the status of an immigrant or permanent resident of another country?
YES ✘ NO
If YES, give details (country):
N/A
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: N/A
b. Are you a person with disability? YES ✘ NO
If YES, please specify ID No: N/A
c. Are you a solo parent? YES ✘ NO
If YES, please specify ID No: N/A

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAME ADDRESS TEL. NO.

ID picture taken within
BLOCK 11 LOT 11 PHASE 3 EASTWIND the last 6 months
ROCHELLE C. ESPIRITU MONTALBAN RIZAL
9674676502 3.5 cm. X 4.5 cm
(passport size)
76A MATIMTIMAN ST.TEACHERS VILLAGE
NUEDA T. ESGUERRA EAST, QUEZON CITY
9065365321 With full and handwritten
name tag and signature over
57F LIBERTY AVE., BRGY. SOCORRO QUEZON printed name
JANE C. UNTALAN CITY
9674672223
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: PROFESSIONAL REGULATION COMMISSION

ID/License/Passport No.: 0666531 Signature (Sign inside the box)

Date/Place of Issuance: 11/09/2000/TUGUEGARAO CITY Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.

AIREEN G. DULFO
Principal III
Person Administering Oath

CS FORM 212 (Revised 2017), Page 4 of 4