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 FIRST NAME MAROHOMSAR
MIDDLE NAME
SHAHANI NAME EXTENSION (JR., SR)

DATE OF BIRTH
3.
2/15/1998 16. CITIZENSHIP Filipino Dual Citizenship
(mm/dd/yyyy) If holder of dual citizenship, please indicate the by birth
by naturalization
details. Pls. indicate country:
4. PLACE OF BIRTH PASIG CITY

5. SEX Male Female

6 CIVIL STATUS Single Married 17. RESIDENTIAL ADDRESS

Widowed
Separated ZIP CODE
House/Block/Lot No. Street
Other/s:
SAN IGNACIO
Subdivision/Village Barangay
7. HEIGHT (m) 1.54 M BUTUAN CITY AGUSAN DEL NORTE
City/Municipality Province
8. WEIGHT (kg) 48

9. BLOOD TYPE O 18. PERMANENT ADDRESS

ZIP CODE
House/Block/Lot No. Street
10. GSIS ID NO. N/A SAN IGNACIO
Subdivision/Village Barangay
11. PAG-IBIG ID NO. 121251403475 BUTUAN CITY AGUSAN DEL NORTE
City/Municipality Province
12. PHILHEALTH NO. 03-02654080-8 8600

13. SSS NO. 08-2936334-2 19. TELEPHONE NO.

N/A
14. TIN NO. 363662906-0000 20. MOBILE NO. 09510391496

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) MAROHOMSARSHAN@GMAIL.COM
N/A
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME FIRST 23. NAME of CHILDREN (Write full name and list all)
NAME
MIDDLE NAME NAME EXTENSION (JR., SR)
N/A N/A
N/A
OCCUPATION
N/A
EMPLOYER/BUSINESS NAME
N/A
BUSINESS ADDRESS
N/A
TELEPHONE NO.
N/A
24. FATHER'S SURNAME FIRST BARRERA
NAME
MIDDLE NAME JR.
ARMANDO

DE LUMEN

25. MOTHER'S MAIDEN NAME

SURNAME FIRST NAME MAROHOMSAR

MIDDLE NAME
LORNA

PLACENCIA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE HIGHEST LEVEL/
LEVEL (Write in full) (Write in full) UNITS EARNED
PERIOD OF ATTENDANCE (if not graduated)

From To
1/6/2004 8/4/2010
ELEMENTARY ONG YIU CENTRAL ELEMENTARY SCHOOL primary education graduated
BUTUAN CITY SCHOOL OF ARTS AND 6/6/2011 4/4/2014
SECONDARY
TRADES secondary education graduated
VOCATIONAL /
 BACHELOR OF ARTS MAJOR IN ENGLISH 5/6/2016 3/29/2019
COLLEGE FATHER SATURNINO URIOS UNIVERSITY LANGUAGE graduated
GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE August 9, 2023

CS FORM 212 (Revised 2017), Page

t the person concerned.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Dual Citizenship
by birth
by naturalization
s. indicate country:

Street
SAN IGNACIO
Barangay
AGUSAN DEL NORTE
Province

Street
SAN IGNACIO
Barangay
AGUSAN DEL NORTE
Province

9510391496

N@GMAIL.COM

DATE OF BIRTH (mm/dd/yyyy)

arate sheet if necessary)

YEAR SCHOLARSHIP/
GRADUATED ACADEMIC
HONORS
RECEIVED

2010
N/A
2014
N/A
 2019
N/A

August 9, 2023

CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY
27.
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL RATING DATE OF PLACE OF EXAMINATION / CONFERMENT
LAWS/ CES/ CSEE (If Applicable) EXAMINATION /
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

N/A

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

10/27/2021 PRESENT OFFICE CLERK JOID FASTLINE CORPORATION 9000.00

7/22/2019 7-25-2020 RECORDS CLERK SAMSON 15000.00

COLLEGE OF SCIENCE AND
1/18/2018 4/18/2023 SANGGUNIANG KABATAAN BARANGAY LOCAL
COUNCIL MEMBER GOVERNMENT UNIT - SAN
IGNACIO

OJT JOB
START FROM YOUR RECENT
WORK
 (Continue on separate sheet if necessary)
SIGNATURE DATE August 9,2023

CS FORM 212 (Revised 2017), Page 2

secondary education graduated

graduated
 LICENSE (if applicable)
Date of
NUMBER Validity

d Work Experience sheet.

STATUS OF GOV'T
APPOINTMENT SERVICE

PERMANENT N

PERMANENT N

ELECTED Y
August 9,2023

CS FORM 212 (Revised 2017), Page 2 of 4

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
29. NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES POSITION / NATURE OF WORK
(Write in full) (mm/dd/yyyy)
NUMBER OF HOURS

From To

N/A

(Continue on separate sheet if necessary)

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

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

From To
SANGGUNIANG KABATAAN MANDATORY TRAINING 5/23/2018 5/23/2018 10 HOURS MANAGE
RIAL
TECHNIC
40hr Construction Occupational Safety and Health (COSH) forSO2 with 2-hour Training 6/16/2019 7/7/2019 40 HOURS
of
Trainers (TOT), CONSAFE30. AL
CAPS LOCK LETTERS tanan

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

32. NON-ACADEMIC DISTINCTIONS / RECOGNITION
(Write in full)
31. SPECIAL SKILLS and HOBBIES

PROFICIENT IN PHOTO AND

VIDEO EDITING N/A
COMMUNICATION SKILLS

COMPUTER LITERATE
( MICROSOFT WORD, EXCEL AND
POWERPOINT)
DOCUMENTATION AND
TECHINICAL PROFICIENY
talents if naa ( kay plus points na sa
agency )

(Continue on separate sheet if necessary)

SIGNATURE DATE
ON/S
POSITION / NATURE OF WORK

CONDUCTED/ SPONSORED BY
(Write in full)

DEPARTMENT OF INTERIOR AND LOCAL

GOVERNMENT
CONSTRUCTION SAFETY TRAINOR AND
CONSULTANT

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
33. (Write in
full)

English Language Society

 graduated
graduated
August 9,2023

graduated
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
b. Have you been criminally charged before any court? If YES, give details:

YES
If YES, give deta
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 YES NO
court or tribunal? If YES, give details:

Have you ever been separated from the service in any of the following modes: resignation, retirement,
37. YES NO
dropped from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in the If YES, give details:
public or private sector?

38.a. Have you ever been a candidate in a national or local election held within the last year (except Barangay YES NO
election)? If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last election to
YES
NO
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 YES NO
(c) Solo Parents Welfare Act of 2000 (RA 8972), please answer the following items: If YES, please specify:
a.
Are you a member of any indigenous group? YES NO
b.
Are you a person with disability? If YES, please specify ID No:
YES NO
c.
Are you a solo parent?
If YES, please specify ID No:

41.
REFERENCES (Person not related by consanguinity or affinity to applicant /appointee) ID picture taken within the last 6 months
4.5 cm. X 3.5 cm (passport size)
Computer generated or photocopied picture is not accepta
NAME ADDRESS TEL. NO. PHOTO

MR. JAMEL P. PANDIIN BGY SAN IGNACIO, BUTUAN CITY

MRS. BELLA P. ANDRADA CUBAO, QUEZON CITY

MR. BOBBY AVENIDO BRGY TINIWISAN, BUTUAN CITY

I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete statement
42.

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
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:

PLEASE INDICATE ID Number and Date of

Government Issued ID: Signature (Sign inside the box)
Date/Place of Issuance: August 9, 2023
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

primary education
secondary education
s:

O
s:

YES NO
If YES, give details:
te Filed:
Case/s:

NO
s:

NO
s:

NO
s:
s:

NO
s (country):

ID picture taken within the last 6 months

4.5 cm. X 3.5 cm (passport size)
Computer generated or photocopied picture is not acceptable
PHOTO

Right Thumbmark
overnment ID as indicated above.

graduated
graduated

graduated