My Pds

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 ag concerned. READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM. 1. CS ID No. Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE.

(Do

I. PERSONAL INFORMATION 2. SURNAME

CATUBIG

NAME EXTENSION (JR., SR

FIRST NAME

ARNIEL

MIDDLE NAME

GERODIAS

3. DATE OF BIRTH (mm/dd/yyyy)

3/5/1991

16. CITIZENSHIP

✘

Filipino

Dual Citizenship by

FORT PIKIT

4. PLACE OF BIRTH 5. SEX 6 CIVIL STATUS

Male

Female

✘

Single

Married

Widowed

Separated

please indicate the details. 17. RESIDENTIAL ADDRESS

Other/s: 7. HEIGHT (m)

1.63 m

8. WEIGHT (kg)

56 kgs

9. BLOOD TYPE

O

11. PAG-IBIG ID NO.

121172205788

12. PHILHEALTH NO.

17-050394800-4

N/A House/Block/Lot No. N/A Subdivision/Village PIKIT City/Municipality

18. PERMANENT ADDRESS

SITTIO

S GIN Ba

NORTH Pr

9409

ZIP CODE

N/A

10. GSIS ID NO.

N/A House/Block/Lot No. N/A Subdivision/Village

PO S

POBL

Ba

MIDSAYAP

NORTH C

City/Municipality

Pr

9410

ZIP CODE

13. SSS NO.

19. TELEPHONE NO.

480-180-290-000

14. TIN NO.

09382005080

20. MOBILE NO.

N/A

15. AGENCY EMPLOYEE NO.

21. E-MAIL ADDRESS (if any)

[email protected]

II. FAMILY BACKGROUND N/A

22. SPOUSE'S SURNAME

23. NAME of CHILDREN (Write full name and list all) NAME EXTENSION (JR., SR)

N/A

FIRST NAME

N/A

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

MIDDLE NAME

24. FATHER'S SURNAME FIRST NAME

by

Pls. indicate cou

If holder of dual citizenship,

✘

birth

CATUBIG ANECITO

NAME EXTENSION (JR., SR)

MIDDLE NAME

JATICO

25. MOTHER'S MAIDEN NAME SURNAME

GERODIAS

FIRST NAME

MEDELINA

MIDDLE NAME

BITONG

(Continue on separate sheet if necessary

III. EDUCATIONAL BACKGROUND NAME OF SCHOOL

26.

LEVEL

(Write in full)

BASIC EDUCATION/DEGREE/COURSE (Write in full)

PERIOD OF ATTENDANCE

From

To

ELEMENTARY

GINATILAN ELEMENTARY SCHOOL

JUNE, 1998

MARCH, 2004

SECONDARY / VOCATIONAL

PIKIT NATIONAL HIGH SCHOOL

JUNE, 2004

MARCH, 2008

ST. JUDE COLLEGE OF SCIENCE & TECH.

HEALTH CARE, EPAS, MAINTAIN & REPAIR CELLULAR PHONE

NOTRE DAME OF MIDSAYAP COLLEGE

BACHELOR OF SECONDARY EDUCATION (BSE-SCIENCE)

TRADE COURSE COLLEGE

HIGHEST LEVEL/ UNITS EARNED (if not graduated)

AUGUST, AUGUST, 2015 2015 JUNE, 2011

3/22/2015

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE

DATE

April

CS FORM

L DATA SHEET

erience Sheet shall cause the filing of administrative/criminal case/s against the person

EFORE ACCOMPLISHING THE PDS FORM. (Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Dual Citizenship by

naturalization

Pls. indicate country:

SITTIO SAGUING

Street GINATILAN Barangay NORTH COTABATO Province

9409 POROK 4 Street

POBLACION 6 Barangay

NORTH COTABATO Province

9410 09382005080 [email protected]

DATE OF BIRTH (mm/dd/yyyy)

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

(Continue on separate sheet if necessary)

YEAR GRADUATED

SCHOLARSHIP/ ACADEMIC HONORS RECEIVED

2004 2008 2015 2015

parate sheet if necessary)

April 7, 2019 CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY 27.

CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEE BARANGAY ELIGIBILITY / DRIVER'S LICENSE

LICENSURE EXAMINATION FOR TEACHER

LICENSE (if ap

RATING (If Applicable)

DATE OF EXAMINATION / CONFERMENT

PLACE OF EXAMINATION / CONFERMENT

77.00

SEPT. 25, 2015

PHILIPPINE COLLEGE OF WOMEN- DAVAO

NUMBER

(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. INCLUSIVE DATES (mm/dd/yyyy)

28.

From

To

SEP. 12, 2018

PRESENT

JUNE, 2015

MARCH, 2018

POSITION TITLE abbreviate)

DEPARTMENT / AGENCY / OFFICE / COMPANY (Write in full/Do not (Write in full/Do not abbreviate)

SHS-TEACHER, DESIGNATED LIBRARIAN SCIENCE TEACHER, LABORATORY INCHARGED

MONTHLY SALARY

SALUNAYAN HIGH SCHOOL

24,224.00

ST. JUDE COLLEGE OF SCIENCE AND TECHNOLOGY, INC.

9,000.00

SALARY/ JOB/ PAY GRADE (if applicable)& STEP (Format "00-0")/ INCREMENT

STATUS OF APPOINTMENT

13-1

PERMANENT CONTRACTUAL

(Continue on separate sheet if necessary)

SIGNATURE

DATE

APRIL 7, 2019

CS FORM 212 (Revised 20

LICENSE (if applicable) Date of Validity

3/5/2019

arate sheet if necessary)

GOV'T SERVICE

(Y/ N)

YES NO

arate 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 29. NAME & ADDRESS OF ORGANIZATION

INCLUSIVE DATES (Write in full) From

N/A

N/A

(mm/dd/yyyy) To

POSITION /

NUMBER OF HOURS

N/A

N/A

(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) 30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS (Write in full)

INCLUSIVE DATES OF ATTENDANCE NUMBER OF HOURS

(mm/dd/yyyy) From

Type of LD ( Managerial/ Supervisory/ Technical/etc)

CONDUCTED/

To

DIVISION YOUTH SCIENCE QUEST AND CAMP 2016

9/17/2016

9/17/2016

Summer 2015 In-Service Training (INSET) for Grade 10 Teachers in Private Schools

4/24/2016

4/27/2016

MUNICIPAL LEVEL SECONDARY MATHEMATICS CAMP OLYMPICS (COACH)

9/22/2017

9/22/2017

TRAINING-WORKSHOP OF FACULTY(Syllabi, Lesson Plans, Test Construction)

5/27/2015

5/29/2015

M 24

Notre Dam

24

St. Jude Coll

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION 31.

SPECIAL SKILLS and HOBBIES

HEALTH CARE SERVICING

32.

MEMBERS

NON-ACADEMIC DISTINCTIONS / RECOGNITION

33.

(Write in full)

PASTORAL INVOLVEMENT

YOUNG

MAINTAIN AND REPAIR CELLPHONE ADOBE PHOTOSHOP READING BOOKS BASKETBALL

(Continue on separate sheet if necessary)

SIGNATURE

DATE

/ PEOPLE / VOLUNTARY ORGANIZATION/S POSITION / NATURE OF WORK

N/A

eparate sheet if necessary)

ROGRAMS ATTENDED five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY (Write in full)

MATALAM HIGH SCHOOL Notre Dame of Dadiangas University (NDDU) Kimagango High School St. Jude College of Science and Technology, Inc.

eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full)

YOUNG EDUCATOR SOCIETY(YES)

eparate sheet if necessary)

APRIL 7, 2019 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.

37.

38.

Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal?

NO

✘

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? ________________________________ END OF CONTRACT ________________________________ a. Have you ever been a candidate in a national or local election held within the last year (except ✘ NO YES Barangay election)? If YES, give details: b. Have you resigned from the government service during the three (3)-month period before the last election to promote/actively campaign for a national or local candidate?

39.

YES

If YES, give details: ________________________________ ________________________________

Have you acquired the status of an immigrant or permanent resident of another country?

YES

✘

NO

✘

NO

If YES, give details: YES

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

YES

✘

NO

If YES, please specify: b.

Are you a person with disability?

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)

42.

NAME

ADDRESS

TEL. NO.

ANNIE M. SAMILLANO, P-II

PIGKAWAYAN N. COTABATO

N/A

JENALYN P. REYES, HT-I

POBLACION MIDSAYAP, COTABATO

N/A

EVANGELINE C. CABILES, MT-II

SALUNAYAN, MID., COTABATO

N/A

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 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.

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

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-DAVAO

ID/License/Passport No.:

1445363

Date/Place of Issuance:

3/5/2015. at PRC-DAVAO

SUBSCRIBED AND SWORN to before me this

Signature (Sign inside the box)

APRIL 7, 2019 Date Accomplished

Right Thumbmark

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

Person Administering Oath

CS FORM 212 (Revised 2017), Page 4 o

If YES, give details (country):

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

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