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 cas
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.

I. PERSONAL INFORMATION
2. SURNAME BONTUYAN

FIRST NAME MARY JANIE

MIDDLE NAME GABATAN

3. DATE OF BIRTH
(mm/dd/yyyy) 9/7/1993 16. CITIZENSHIP
Filipino
Dual Citi
FILIPINO

4. PLACE OF BIRTH BUENAVISTA, PAGADIAN CITY If holder of dual citizenship,

please indicate the details.

5. SEX Male Female

Single Married 17. RESIDENTIAL ADDRESS

6 CIVIL STATUS
House/Block/Lot No.
Widowed Separated
Other/s:
Subdivision/Village
PAGADIAN
7. HEIGHT (m) 1.50M
City/Municipality
8. WEIGHT (kg) 55 KG ZIP CODE 7016

18. PERMANENT ADDRESS

9. BLOOD TYPE AB
House/Block/Lot No.

10. GSIS ID NO. N/A

Subdivision/Village
PAGADIAN
11. PAG-IBIG ID NO. 1211-2119-5672
City/Municipality

12. PHILHEALTH NO. 14-050191165-4 ZIP CODE 7016

13. SSS NO. 10-1035233-6 19. TELEPHONE NO. N/A

14. TIN NO. 454-779-317-000 20. MOBILE NO. 09563379745 / 09464969270

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) maryjanieb090793@
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME N/A N/A N/A
MIDDLE NAME N/A N/A
OCCUPATION N/A N/A
EMPLOYER/BUSINESS NAME N/A N/A
BUSINESS ADDRESS N/A N/A
TELEPHONE NO. N/A N/A
24. FATHER'S SURNAME BONTUYAN N/A
NAME EXTENSION (JR., SR)
FIRST NAME SANTOS N/A N/A
MIDDLE NAME CARACUT N/A
25. MOTHER'S MAIDEN NAME N/A
SURNAME GABATAN N/A
FIRST NAME REMEDIOS N/A
MIDDLE NAME BELOTINDOS (Continue on separate sheet i

III. EDUCATIONAL BACKGROUND

26. NAME OF SCHOOL PERIOD OF ATTENDANCE

BASIC EDUCATION/DEGREE/COURSE
LEVEL (Write in
(Write in full)
full)
From To

ELEMENTARY BUENAVISTA ELEMENTARY SCHOOL PRIMARY EDUCATION 6/1/2000 3/30/2006

NORBERTA GUILLAR MEMORIAL NATIONAL HIGH

SECONDARY
SCHOOL
SECONDARY EDUCATION 6/1/2006 4/30/2010
VOCATIONAL /

PHILIPPINE TECHNOLOGICAL MARINE SCIENCES FOOD AND BEVERAGE NC II 12/1/2013 3/30/2014

TRADE
COURSE
COLLEGE WESTERN MINDANAO STATE UNIVERSITY BEED-GENERAL EDUCATION 6/1/2010 4/8/2014

GRADUATE STUDIES SAINT COLUMBAN COLLEGE MAED-FILIPINO 10/1/2015 PRESENT

(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 17, 2017

AL DATA SHEET
Experience Sheet shall cause the filing of administrative/criminal case/s against the person

DS) BEFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR) N/A

Filipino Dual Citizenship

by birth by naturalization
Pls. indicate country:

Street
BUENAVISTA
Barangay
ZAMBOANGA DEL SUR
Province
7016

Street
BUENAVISTA
Barangay
ZAMBOANGA DEL SUR
Province

N/A

09563379745 / 09464969270

maryjanieb090793@gmail.com

23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

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)

HIGHEST LEVEL/ SCHOLARSHIP/

YEAR
UNITS ACADEMIC
GRADUATED
EARNED HONORS
(if not graduated) RECEIVED

GRADUATED 2006 1ST HONORS

CLASS
GRADUATED 2010 SALUTATURIAN
 GRADUATED 2014 NC II

TOP 2 MERITORIOUS
GRADUATED 2014 STUDENT

24 UNITS N/A N/A

ue on separate sheet if necessary)

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 ap
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

SOUTHERN MINDANAO COLLEGE- COLLEGE

LICENSURE EXAMINATION FOR TEACHER 78.6 8/17/2014 1326907
DEPARTMENT,PAGADIAN CITY

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

DEPARTMENT OF EDUCATION- LA SUERTE

6/1/2014 4/30/2016 TEACHER- 1 P 19,620.00 "11-1" REGULAR
E/S
DEPARTMENT OF EDUCATION- LA SUERTE
6/13/2016 PRESENT CLASSROOM TEACHER P 5,000.00 N/A CONTRACTUAL
E/S
 (Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 17, 2017 CS FORM 212 (Revised 2017), P

 LICENSE (if applicable)

Date of
Validity

11/21/2014

te sheet if necessary)

GOV'T
SERVICE

(Y/ N)

YES

NO
te sheet if necessary)

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 POSITIO
From To

BUENAVISTA CHAPEL-YOUTH ORGANIZATION 1/1/2016 PRESENT YOUTH VICE -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/ CONDUCTE
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/
Technical/etc)
From To
REGIONAL MASS TRAINING OF MULTIGRADE TEACHERS ON DIFFERENTIATED
3/10/2017 3/18/2017 72 HOURS DEPED-ZA
INSTRUCTIONS
TRAINING ORIENTATION-WORKSHOP ON MULTIGRAGDE TEACHERS ON THE
1/11/2017 1/18/2017 72 HOURS
UTILIZATION OF BUDJET OF WORK AND LEVELED READERS

ORIENTATION ON DISASTER RISK REDUCTION AND MANAGEMENT 8/26/2016 8/26/2016 8 HOURS

REVISITING HUNDERED LANGUAGES OF CHILDREN: RECONSTRUCTION OF LEARNING 5/21/2015 2/22/2015 16 HOURS

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION

31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

1ST RUNNER UP COACH IN THE STORY READING-PRIVATE SCHOOL CATEGORY (DIVISION YOUTH
TEACHING
LEVEL)
ENCODING DOCUMENTS 2ND RUNNER-UP COACH IN THE HAND WRITING CONTEST (DIVISION LEVEL)
 (Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 20, 2017

LE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

YOUTH VICE -PRESIDENT

separate sheet if necessary)

MS ATTENDED
ve (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

DEPED-ZAMOANGA DEL SUR DIVISION

DEPED-PAGADIAN CITY DIVISION

PAGADIAN CITY DIVISION

PAGADIAN CITY GOLDEN SCHOOL

separate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

YOUTH VICE-PRESIDENT (BUENAVISTA

CHAPEL)
separate sheet if necessary)

APRIL 20, 2017 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? ________________________________
FINISHED CONTRACT
________________________________
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 w
the last 6 mon
MARY ANN M. DURAN LA SUERTE PAGADIAN CITY 3.5 cm. X 4.5 c
(passport size
PAGADIAN CITY CHAMBER SCHOOL-LOWER
HAYDEE G. APATAN DAO PAGADIAN CITY With full and hand
name tag and signat
printed name

Computer gener
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete or photocopied pi
is not acceptab
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 administrative/criminal case/s PHOTO
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.: 1326907

Signature (Sign inside the box)
APRIL 20, 2017
Date/Place of Issuance: 11/18/2014- PRC PAGADIAN
Date Accomplished Right Thumbma

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated

Person Administering Oath

CS FORM 212 (Revised

 If YES, give details:
________________________________

If YES, give details:

________________________________
________________________________

If YES, give details:

________________________________
________________________________

If YES, give details:

________________________________
________________________________

If YES, give details:

________________________________
FINISHED CONTRACT
________________________________
NO

NO

NO
If YES, give details (country):

NO

NO

NO

ID picture taken within

the last 6 months
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten

name tag and signature over
printed name

Computer generated
or photocopied picture
is not acceptable

PHOTO

Right Thumbmark

, affiant exhibiting his/her validly issued government ID as indicated above.

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