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 BORNALES
NAME EXTENSION (JR., SR)
FIRST NAME HAJJ
MIDDLE NAME PICAYCO
3. DATE OF BIRTH
(mm/dd/yyyy) 11/21/1994 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH CADIZ CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS Purok Kalubihan

House/Block/Lot No. Street
Separat
Widowed Daga
Other/s: ed Subdivision/Village Barangay
Cadiz Negros Occidental
7. HEIGHT (m) 1.53 m
City/Municipality Province
8. WEIGHT (kg) 57 kg ZIP CODE 6121
18. PERMANENT ADDRESS Purok Kalubihan
9. BLOOD TYPE "B+"
House/Block/Lot No. Street
Daga
10. GSIS ID NO. 2005345685
Subdivision/Village Barangay
Cadiz Negros Occidental
11. PAG-IBIG ID NO. 1211-7446-2030
City/Municipality Province

12. PHILHEALTH NO. 11-2517828976-8 ZIP CODE 6121

13. SSS NO. N/A 19. TELEPHONE NO. N/A
14. TIN NO. 333-176-008-000 20. MOBILE NO. +639272048672
15. AGENCY EMPLOYEE NO. TCH1-452650-1998 21. E-MAIL ADDRESS (if any) hajj.bornales@deped.gov.ph / hajjbornales1121@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)
FIRST NAME N/A N/A N/A

MIDDLE NAME N/A N/A N/A

OCCUPATION N/A N/A N/A

EMPLOYER/BUSINESS NAME N/A N/A N/A

BUSINESS ADDRESS N/A N/A N/A

TELEPHONE NO. N/A N/A N/A

24. FATHER'S SURNAME BORNALES

NAME EXTENSION (JR., SR)
FIRST NAME HARLIE

MIDDLE NAME TOLECO

25. MOTHER'S MAIDEN NAME

SURNAME PICAYCO

FIRST NAME JULIETA

MIDDLE NAME MAGNO (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

1st Honorable
ELEMENTARY SPED TRAINING CENTER N/A 1/6/2002 1/4/2008 Graduated 2008 Mention

With Honors;
SECONDARY /
VOCATIONAL SPED HIGH SCHOOL N/A 1/6/2008 1/4/2012 Graduated 2012 Leadership Awardee

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

TRADE
COURSE
COLLEGE Philippine Normal University - Visayas BSED- Major in Filipino 1/6/2012 1/4/2016 Graduated 2016 Dean's Lister

GRADUATE STUDIES La Carlota City College MaEd Filipino 1/6/2018 Present 27 units N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE August 20, 2020

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
Release

Licensure Examination for Teachers 82.6 09/25/2016 UC Mambaling, Cebu City 1492031 12/13/2016

(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 SERVICE
SALARY/ JOB/ PAY
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
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)

1/6/2016 1/4/2018 Teacher La Consolacion College Bacolod SHS Department 14, 850 0-0 Part Time N
02/22/2020 Present Teacher I Villacin National High School (DepEd) 20179.00 11-1 Permanent Y

(Continue on separate sheet if necessary)

SIGNATURE DATE August 20, 2020

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

Mother Rita Barcelo Night High School Program 1/6/2016 03/31/2017 344.0 Teacher

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED

INCLUSIVE DATES OF
ATTENDANCE
30. Type of LD
TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ( Managerial/ CONDUCTED/ SPONSORED BY
(mm/dd/yyyy) NUMBER OF HOURS
Supervisory/
(Write in full) (Write in full)
Technical/etc)

From To

Regional Orientation and Simulation on Microsoft Teams August 11, 2020 August 11, 2020 4hrs Supervisory DEPED Region VI hosted by SDO Iloilo

Regional Orientation and Simulation on QuipperSchool August 7, 2020 August 7, 2020 4hrs Supervisory DEPED Region VI hosted by SDO Sagay
Regional Orientation and Simulation on Hubhuman August, 6 2020 August 6, 2020 4 hrs Supervisory DEPED Region VI hosted by SDO Sagay and Bago

Regional Orientation and Simulation on Schoology August 3, 2020 August 4, 2020 8 hrs Supervisory DEPED Region VI hosted by SDO Aklan

Regional Orientation and Simulation on Google Classroom July 28, 2020 July 28, 2020 4hrs Supervisory DEPED Region VI hosted by SDO Roxas

Orientation on Most Essential Learning Competencies July 27, 2020 July 27, 2020 4hrs Supervisory DEPED Division of Cadiz City

Learning Management System for Online Delivery Modality July 22, 2020 July 24, 2020 24hrs Supervisory DEPED Region VI

Capacity Building for Youth Development Sept. 21, 2019 Sept. 22, 2019 16hrs Supervisory Division GSP

Council Training on Girl Powered Nutrition April 22, 2019 April 24, 2019 24hrs Supervisory
WAGGS and Provincial GSP Council
Training Opportunities in Reaching for Children's Hands Dec. 4, 2018 Dec. 7, 2018 32hrs Supervisory
DEPED Division of Cadiz City

Regional Press Conference on School Campus Journalism Nov. 29, 2018 Nov. 30, 2018 16hrs Supervisory DEPED Region VI

Career Advocates Reaching Out to Everyone Nov. 8, 2018 Nov. 8, 2018 8hrs Supervisory
DEPED Division of Cadiz City

Teacher Induction Program Oct. 15, 2018 Oct. 17, 2018 24hrs Supervisory DEPED Division of Cadiz City

Division Secondary Schools Press Conference Oct. 1, 2018 Oct. 3, 2018 24hrs Supervisory DEPED Division of Cadiz City

Outdoor Leadership Course Training Sept. 7, 2018 Sept. 9, 2018 32hrs Supervisory Regional GSP Council

TIP: A Step Towards Becoming a Proficient and Committed Teacher Aug. 20, 2018 Aug. 20, 2018 8hrs Supervisory DEPED Region VI

Capacity Building of the Core Curriculum Contexualizers for Grade 9 and 11 Teachers Mar. 7, 2018 Mar. 9, 2018 24 hrs Supervisory DEPED Division of Cadiz City

National Certificate III in Events Management Services April 26, 2018 April 28, 2018 108hrs Supervisory TESDA Region VII

Dance Xchange Program: The Philippine International Dance Festival April 26, 2018 April 28, 2018 24hrs Supervisory National Commission for Culture and the Arts

Sustaining the Gains, Closing the Gaps: Mandate for Teachers May 21, 2018 May 25, 2018 40hrs Supervisory DEPED Division of Cadiz City

Effective Teaching Strategies Jan. 5, 2018 Jan. 5, 2018 3hrs Supervisory La Consolacion College Bacolod SHS Department

Diiwa Innovators Congress Nov. 11, 2017 Nov. 11, 2017 8 hrs Supervisory Diwa Learning Systems Inc.

Building Resilience to Cope with Depression Oct. 27, 2017 Oct. 27, 2017 8 hrs Supervisory La Consolacion College Bacolod HRD

Senior High School Subject Content Mastery March 4, 2017 March 4, 2017 8 hrs Supervisory Rex Book Store

Building Blocks: The 21st Century Classroom Techniques and Style in Handling Millenials May 5, 2017 May 5, 2017 8 hrs Supervisory C&E Publishing Inc.

Service Learning as a Teaching Pedagogy July 29, 2016 July 29, 2016 8 hrs Supervisory La Consolacion College Bacolod Academic Affairs Office

(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 and Baking N/A N/A

Dancing N/A N/A

Computer-related skills N/A N/A

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

N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE August 20, 2020

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
Prof. Raymund Santiago, LPT, MaEd, Ph. D Bago City 9612881640 4.5 cm. X 3.5 cm
(passport size)

Prof. Ralger Jocson Jr., LPT, MaEd, Ph. D Cadiz City 9189351915
Computer generated
or photocopied picture
Architect Jireh Joan A. Tolentino Cadiz City 9158554398 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: GSIS ID

ID/License/Passport No.: 011-1636-8559-4

Signature (Sign inside the box)

Date/Place of Issuance: Bacolod City

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