Professional Documents
Culture Documents
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 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 DELOS SANTOS
14. TIN NO. 430 - 085 - 893 - 000 20. MOBILE NO. 09772006983
15. AGENCY EMPLOYEE NO. 4649761 21. E-MAIL ADDRESS (if any)
joan_d37@yahoo.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME DELOS SANTOS 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) RIANNE TIFFANY DELOS SANTOS
FIRST NAME RENANTE NONE
OCCUPATION NONE
SURNAME CAPISNON
TRADE
COURSE
COLLEGE LEYTE STATE UNIVERSITY BACHELOR OF SECONDARY EDUCATION 1998 2003
SIGNATURE DATE
AL DATA SHEET
k Experience Sheet shall cause the filing of administrative/criminal case/s against the person
by birth by naturalization
Street
PASOL
Barangay
CEBU
Province
6023
Street
PASOL
Barangay
CEBU
Province
6023
NONE
09772006983
joan_d37@yahoo.com
23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
COLLEGE
GRADUATED 2003 HONORS
May 3, 2017
LICENSURE EXAMINATION FOR TEACHERS (LET) 82.80% 08/31/2003 TACLOBAN CITY, LEYTE
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
(Write in full/Do not (Write in SALARY
applicable)& STEP
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To
CS FORM 21
LICENSE (if applicable)
NUMBER Date of
Validity
832622 3/2/2004
(Y/ N)
REGULAR/
YES
PERMANENT
REGULAR/
YES
PERMANENT
REGULAR/
YES
PERMANENT
REGULAR/
YES
PERMANENT
CONTRACTUAL YES
CONTRACTUAL YES
CONTRACTUAL YES
CONTRACTUAL NO
e on separate sheet if necessary)
NATION
READING BOOKS NONE
SIGNATURE DATE
E / VOLUNTARY ORGANIZATION/S
N/A
CONDUCTED/ SPONSORED BY
(Write in full)
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in
full)
NATIONAL ORGANIZATION OF PROFESSIONAL
TEACHERS INCORPORATED
MAY 3, 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? ________________________________
________________________________
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:
ROGER D. BANOGBANOG GUIWANG, ALCOY, CEBU 483 - 8052 With full and hand
name tag and signa
printed nam
WENDELYN E. PANSAON ALCOY, CEBU 483 - 9172
Computer gene
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied p
is not accepta
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
SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated
NO
NO
If YES, give details (country):
NO
NO
NO
Computer generated
or photocopied picture
is not acceptable
PHOTO
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