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 REBOJO
NAME EXTENSION (JR., SR)
FIRST NAME MARYCRIS

MIDDLE NAME AVERGONZADO

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) July 18, 1985 ✘ Filipino Dual Citizenship

by birth ✘ by naturalization
4. PLACE OF BIRTH Alegria, Surigao del Norte If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX
Male ✘ Female
6 CIVIL STATUS
17. RESIDENTIAL ADDRESS N/A PUROK 1
Single ✘ Married House/Block/Lot No. Street
Widowed ✘ Separated N/A QUANO
Other/s:
Subdivision/Village Barangay
7. HEIGHT (cm) 160 (cm) ALEGRIA SURIGAO DEL NORTE
City/Municipality Province
8. WEIGHT (kg) 60 (kg) ZIP CODE 8425

9. BLOOD TYPE B+
18. PERMANENT ADDRESS N/A PUROK 1
House/Block/Lot No. Street
10. GSIS ID NO. N/A
N/A QUANO
Subdivision/Village Barangay
Alegria Surigao del Norte
11. PAG-IBIG ID NO. N/A
City/Municipality Province

12. PHILHEALTH NO. 180252286398 ZIP CODE 8425

13. SSS NO. 0824840585 19. TELEPHONE NO. N/A

14. TIN NO. N/A 20. MOBILE NO. 09856176546

15. AGENCY EMPLOYEE NO.
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME
FIRST NAME
N/A 21. E-MAIL ADDRESS (if any) avergonzadomarycris72@gmail.com
REBOJO 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
EMMANUEL KENT JOHN A. REBOJO August 11, 2004

MIDDLE NAME ONG NEIL BRYAN A. REBOJO January 5, 2010

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME DECEASED

NAME EXTENSION (JR., SR)
FIRST NAME DECEASED

MIDDLE NAME DECEASED

25. MOTHER'S MAIDEN NAME KALAW

SURNAME AVERGONZADO

FIRST NAME LESLIE

MIDDLE NAME BANLUTA (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
(Write in full) HONORS
full) (if not graduated) RECEIVED
From To

ELEMENTARY Alegria Central Elementary School Primary 1999 2000 Graduated 2000 N/A

SECONDARY /
VOCATIONAL Alegria National High School Secondary 2000 2004 Graduated 2004 N/A

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

TRADE
COURSE
COLLEGE Caraga Institute of Technology Bachelor of Elementary Education

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE March 13, 2023

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

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

Licensure Examination for Teacher 75.0 October 2, 2022 Butuan City Caraga 1970128 July 18, 2026

(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. SALARY/ JOB/ PAY
INCLUSIVE DATES (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)
Not
June 1, 2021 Present Saleslady Apple Mart 9,000.00 "00-0" N
Permanent
Not
June/28/2018 Nov/20/2020 Overseas Filipino Worker (Nanny and Tutor) Anasia Travel and Toursim - LLC 25,000.00 "00-0" N
Permanent
MENRO - Municipal Environmental Natural Not
January 5, 2017 June/28/2018 Office Clerk (Job Order) 5,500.00 "00-0" N
Resources Office - Alegria Municipality Permanent
Not
March 1, 2011 December 12, 2016 Office Clerk (Job Order) Engineering Office - Alegria Municipality 5,500.00 "00-0" N
Permanent

(Continue on separate sheet if necessary)

SIGNATURE DATE March 13, 2023

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

(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

Certificate of Completion- SEMINAR/ WORKSHOP ON STRATEGIC HUMAN RESOURCE PLAN October 12, 2017 October 13, 2017 16.0 Technical Local Government Unit Alegria, Surigao del Norte

Certificate of Commendation - Cathechist Alegria Central Elementary School April 1, 2011 April 30, 2011 240.0 Technical Alegria Central Elementary School

CERTIFICATE OF APPRECIATION - Board of Judges Barangay Street and Purok Centers

December 30, 2012 December 30, 2012 8.0 Technical Brgy. San Pedro, Alegria Surigao del Norte
Christmas Beautification Contest
CERTIFICATE OF APPRECIATION - Board of Judges Barangay Christmas Sing and Dance
December 24, 2012 December 24, 2012 8.0 Technical Brgy. San Pedro, Alegria Surigao del Norte
Contest
CERTIFICATE OF Participation - Training Workshop on Ecological Solid Waste Management on
October 30, 2008 October 31, 2008 16.0 Technical Local Government Unit Alegria, Surigao del Norte
Project Advocay for a Clean Environment and Its Sustainability
Ma. Rebecca E. Bagnol - Provincial Agriculturist
CERTIFICATE OF Completion-School on the Air on Sustainable Corn Production July 18, 2016 November 23, 2016 100.0 Technical
Covention Hall, Province of Surigao del Norte
Edna M. Mabeza, PhD. OIC Regional Excutive Director
CERTIFICATE OF PARTICIPATION - Basic Meat Processing Training May 22, 2012 May 23, 2012 16.0 Technical
Municipal Training Center Alegria Surigao del Norte

Nenita D. Sumile, EdD. Center Director - Agricultural

CERTIFICATE OF TRAINING - Hands-on Training on Image Editing September 9, 2013 September 12, 2023 32.0 Technical Training Institute Mt. Bagarabon Beach Hotel
&Mountain, Mabua Surigao City
Ma. Rebecca E. Bagnol - Provincial Agriculturist
Certificate of Training - School on the Air (SOA) on Organic Agriculture June 1, 2013 October 31, 2013 100.0 Technical
Covention Hall, Province of Surigao del Norte

CERTIFICATE OF PARTICIPATION - Basic Meat Processing Training August 19, 2014 August 20, 2014 16.0 Technical Local Government Unit Alegria, Surigao del Norte

Certificate of participation- MASIPAG ORIENTATION SEMINAR ON ORGANIC AGRICULTURE April 14, 2014 April 15, 2014 16.0 Technical Local Government Unit Alegria, Surigao del Norte

Edna M. Mabeza, PhD. OIC Regional Excutive Director

Certificate of Participation - Organic Rice Production Technology Training December 11, 2013 December 13, 2013 32.0 Technical
Municipal Training Center Alegria Surigao del Norte

(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

Cleaning

Computer Literate

(Continue on separate sheet if necessary)

SIGNATURE DATE March 13, 2023

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
by any court or tribunal? YES ✘ NO
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
Atty. Ma. Lourdes D. Ugay Brgy. Anahaw, Alegria, SDN 3.5 cm. X 4.5 cm
(passport size)

Aicel K. Ibbara Brgy. Washington, Surigao City With full and handwritten
name tag and signature over
Teachers Village, Brgy. Cagniog, Surigao printed name
Atty. Fernando T. Larong City 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: PRC

ID/License/Passport No.: 1970128

Signature (Sign inside the box)
March 13, 2023
Date/Place of Issuance: Butuan 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