CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misinterpretation 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 QUERIDO

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

MIDDLE NAME ROBINA

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 11/27/2005 ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH URDANETA CITY, PANGASINAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS 310

Widowed Separated House/Block/Lot No. Street

SAN JOSE
Other/s:
Subdivision/Village Barangay
URDANETA CITY PANGASINAN
7. HEIGHT (m) 5'7
City/Municipality Province
8. WEIGHT (kg) 56 ZIP CODE 2428
18. PERMANENT ADDRESS 310
9. BLOOD TYPE O+
House/Block/Lot No. Street
SAN JOSE
10. GSIS ID NO. 4404 5260 0047 4013
Subdivision/Village Barangay
URDANETA CITY PANGASINAN
11. PAG-IBIG ID NO. 2547-3659-2510
City/Municipality Province

12. PHILHEALTH NO. 12-594721583-4 ZIP CODE 2428

13. SSS NO. 61-6871254-9 19. TELEPHONE NO. 09563524194

14. TIN NO. 587-876-999 20. MOBILE NO. 09760083256

15. AGENCY EMPLOYEE NO. 1215224 21. E-MAIL ADDRESS (if any) mjquerido30@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) N/A
FIRST NAME 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 QUERIDO

NAME EXTENSION (JR., SR)
FIRST NAME JIMMY

MIDDLE NAME ALMENDARES

25. MOTHER'S MAIDEN NAME ROBINA

SURNAME ROBINA

FIRST NAME MAGNOLIA

MIDDLE NAME GALLARIN (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

JOURNALIST
ELEMENTARY SAN JOSE ELEMENTARY SCHOOL BASIC EDUCATION 2010 2016 N/A 2016 OF THE YEAR

DON ANTONIO BONGOLAN MEMORIAL WITH HIGH

SECONDARY /
VOCATIONAL SECONDARY EDUCATION 2017 2023 N/A 2023
HIGH SCHOOL HONORS

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

TRADE
COURSE BACHELOR OF SECONDARY
COLLEGE URDANETA CITY UNIVERSTIY 2023 2027 N/A 2028 CUM LAUDE
EDUCATION MAJOR IN FILIPINO

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

LICENSURE EXAMINATION FOR TEACHERS 91.50% OCTOBER 5, 2028 URDANETA CITY NATIONAL HIGH SCHOOL 121522 11/27/2031

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

12/15/2028 2/12/2029 TEACHER II DEPARTMENT OF EDUCATION 20000.00 25 HIRED GSIS

(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

SCHOOL SUPREME GOVERNMENT 2/9/2022 12/6/2023 4 HOURS PRESIDENT

YOUNG PEOPLE NATURE'S LOVERS CLUB 12/9/2023 05/20/2024 3 HOURS PRESIDENT

(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

DISTRICT IN-SERVICE TRAINING FOR TEACHERS 01/05/2029 01/09/2029 50 HOURS PARTICIPANT URDANETA CITY NATIONAL HIGH SCHOOL

MEMBERHIP SEMINAR (JSESTEA-MPC) 02/22/2029 02/22/2029 8 HOURS TECHNICAL URDANETA CITY NATIONAL HIGH SCHOOL

SUMMER IN- SERVICE TRAINING 05/23/2029 05/25/2029 30 HOURS TECHNICAL URDANETA CITY NATIONAL HIGH 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 full)
(Write in full)

COMPUTER LITERATE N/A SSG PRESIDENT

YOUNG PEOPLE NATURE'S LOVERS CLUB
LEADERSHIP SKILLS
PRESIDENT
WELL-SPOKEN FILIPINO CLUB PRESIDENT

FAST LEARNER KAPISANG FILIPINO REPRESENTATIVE

(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 ✘ NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘ NO
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
BARTOLOME PALAGUD SAN JOSE, URDANETA CITY 9257618643 the last 6 months
3.5 cm. X 4.5 cm
NERISSA M. DE LOYOLA SAN JOSE, URDANETA CITY 9845713548 (passport size)

LILIBETH D. DORIANO SAN JOSE, URDANETA CITY 9873659962 With full and handwritten
name tag and signature over
printed name
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 Computer generated
or photocopied picture
Philippines. I authorize the agency head / authorized representative to verify/validate the contents stated herein. I is not acceptable
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: 4162951234567890

ID/License/Passport No.: DO1-12-257916 Signature (Sign inside the box)

Date/Place of Issuance: MANILA

OCTOBER 20, 2029
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this JANUARY 7, 2019 , affiant exhibiting his/her validly issued government ID as indicated above.

DR. FERDINAND B. MILLAN

Person Administering Oath

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