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 DEQUILLA
NAME EXTENSION (JR., SR)
FIRST NAME AVELYN

MIDDLE NAME JAMORA

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS N/A PUROK DAHLIA
House/Block/Lot No. Street
Separat
Widowed N/A LUY-A
Other/s: ed Subdivision/Village Barangay
AROROY MASBATE
7. HEIGHT (m) 1.57
City/Municipality Province
8. WEIGHT (kg) 64.5 ZIP CODE 5414

18. PERMANENT ADDRESS N/A PUROK DAHLIA

9. BLOOD TYPE O
House/Block/Lot No. Street
N/A LUY-A
10. GSIS ID NO. 02004343232
Subdivision/Village Barangay
AROROY MASBATE
11. PAG-IBIG ID NO. 121093894114
City/Municipality Province

12. PHILHEALTH NO. LP02004343232 ZIP CODE 5414

13. SSS NO. N/A 19. TELEPHONE NO. 578-5411/578-5300

14. TIN NO. 433-470-121 20. MOBILE NO. 09647285830

15. AGENCY EMPLOYEE NO. 4124776 21. E-MAIL ADDRESS (if any) AVZJAMZ40@GMAIL.COM
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME DEQUILLA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME ARIEL N/A IVAN J. DEQUILLA JUNE 25, 2002

MIDDLE NAME BARRUGA

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME JAMORA

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

MIDDLE NAME BORNALEZ

25. MOTHER'S MAIDEN NAME

SURNAME VASQUEZ

FIRST NAME AVE

MIDDLE NAME ARABIZ (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY LUY-A ELEMENTARY SCHOOL ELEMENTARY GRADUATE N/A 1995 SALUTURIAN

SECONDARY LUY-A NATIONAL HIGH SCHOOL HIGH SCHOOL GRADUATE

SECOND
HONOR

VOCATIONAL /
BREAD AND PASTRY NC II,
FOOD PROCESSING NC II,
ORGANIC AGRICULTURE PRODUCTION NC II ,
MIASBATE INSTITUTE OF TECHNOLOGY
COOKERY NC II, FOOD AND BEVERAGE NC II HOLDER N/A
SERVICES NC II,TRAINORS METHODOLOGY I WITH
TRADE
NTTC HOLDER
COURSE

DR.EMILIO B. ESPINOSA SR., MEMORIAL STATE COLLEGE

COLLEGE BSED-BIOLOGY
OF AGRICULTURE AND TEACHNOLOGY

DR.EMILIO B. ESPINOSA SR., MEMORIAL STATE COLLEGE

GRADUATE STUDIES
OF AGRICULTURE AND TEACHNOLOGY
MA 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

LICENSURE EXAMINATION FOR TEACHERS 75.2 12/3/2012 LEGASPI 1145528 04/20/2023

(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.
SALARY/ GOV'T
JOB/ PAY SERVICE
28. INCLUSIVE DATES GRADE (if
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY applicable)& STATUS OF
(Write in full/Do not (Write in SALARY STEP APPOINTMENT
abbreviate) full/Do not abbreviate) (Format "00-
From To 0")/
INCREMENT (Y/ N)

9/1/2013 OCT 2, 2022 TEACHER I DEPARTMENT OF EDUCATION -MASBATE 24889.00 11-3 PERMANENT Y

OCT 3, 2022 PRESENT TEACHER II DEPARTMENT OF EDUCATION -MASBATE 29165.00 PERMANENT Y

(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
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

(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)

COOKING N/A N/A

BAKING

SINGING

(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:

________________________________

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
YES ✘ NO
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:
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
BERMIE DOCTOLERO MILAGROS MASBATE 9103800328 4.5 cm. X 3.5 cm
(passport size)

ESTER R. SANTILLAN AMBOLONG, AROROY, MASBATE 9185340407

Computer generated
or photocopied picture
MARCEL ONO PALAD DIMASALANG,MASBATE 9090650939 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 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: NATIONAL ID

ID/License/Passport No.: 4129-4860-5195-3743

Signature (Sign inside the box)

Date/Place of Issuance: AUGUST 14,2021

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