Pds.xls
This document was uploaded by user and they confirmed that they have the permission to share it. If you are author or own the copyright of this book, please report to us by using this DMCA report form. Report DMCA
Overview
Download & View Pds.xls as PDF for free.
More details
- Words: 1,398
- Pages: 12
CS Form No. 212 Revised 2017
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
Amparo
2. SURNAME FIRST NAME
Lalaine
MIDDLE NAME
Galang
NAME EXTENSION (JR., SR)
3. DATE OF BIRTH (mm/dd/yyyy)
2/5/1994
16. CITIZENSHIP
✘
Filipino
Dual Citizenship by birth
Unisan, Quezon
4. PLACE OF BIRTH
Male
5. SEX 6 CIVIL STATUS
✘
Single Widowed Other/s:
7. HEIGHT (m)
160m
8. WEIGHT (kg)
50kg
9.
✘
Female
please indicate the details.
Married 17. RESIDENTIAL ADDRESS Separated
by naturalization
Pls. indicate country:
If holder of dual citizenship,
Philippines House/Block/Lot No. J.B Village Subdivision/Village Sta. Rosa City/Municipality
ZIP CODE
Street Balibago Barangay Laguna Province 4026
18. PERMANENT ADDRESS
BLOOD TYPE
House/Block/Lot No.
Street Almacen
10. GSIS ID NO. 11. PAG-IBIG ID NO.
1211-5338-0174
12. PHILHEALTH NO.
08-051476883
13. SSS NO.
04-3566765-2
19. TELEPHONE NO.
971-293-000
20. MOBILE NO.
14. TIN NO.
Barangay Quezon
City/Municipality
Province
4305
ZIP CODE
15. AGENCY EMPLOYEE NO.
Subdivision/Village Unisan
09076960830
[email protected]
21. E-MAIL ADDRESS (if any)
II. FAMILY BACKGROUND 22.
SPOUSE'S SURNAME
23. NAME of CHILDREN (Write full name and list all)
DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME MIDDLE NAME OCCUPATION EMPLOYER/BUSINESS NAME BUSINESS ADDRESS TELEPHONE NO. 24.
25.
FATHER'S SURNAME
Amparo
FIRST NAME
Ricardo
MIDDLE NAME
De Guzman
NAME EXTENSION (JR., SR)
MOTHER'S MAIDEN NAME SURNAME
Galang
FIRST NAME
Eulalia
MIDDLE NAME
Trinidad
(Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND 26.
NAME OF SCHOOL LEVEL
(Write in full)
BASIC EDUCATION/DEGREE/COURSE (Write in full)
PERIOD OF ATTENDANCE
HIGHEST LEVEL/ YEAR UNITS GRADUATED EARNED (if not graduated)
NAME OF SCHOOL LEVEL
(Write in full)
ELEMENTARY SECONDARY / VOCATIONAL
TRADE COURSE COLLEGE
BASIC EDUCATION/DEGREE/COURSE (Write in full) From
To
Almacen Elementary School
June 2001
March 2006
Leonarda De Vera Cruz National High School
June 2006
March 20010
June 2010
March 2014
Polytechnic University of the Philippines(Unisan Branch)
Bachelor of Science in Elementary Education
HIGHEST LEVEL/ YEAR UNITS GRADUATED EARNED (if not graduated)
GRADUATE STUDIES
(Continue on separate sheet if necessary)
SIGNATURE
DATE
January 22, 2019 CS FORM 212 (Revised 2017), Page 1 of
son concerned.
t fill up. For CSC use only)
ON (JR., SR)
naturalization
t go ay
a ce
t
en
ay n
ce
OF BIRTH (mm/dd/yyyy)
SCHOLARSHIP/ ACADEMIC HONORS RECEIVED
SCHOLARSHIP/ ACADEMIC HONORS RECEIVED
2, 2019
2 (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(LET)
RATING (If Applicable)
DATE OF EXAMINATION / CONFERMENT
PLACE OF EXAMINATION / CONFERMENT
77.40%
3/29/2015
Lucena 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 (mm/dd/yyyy)
POSITION TITLE (Write in full/Do not abbreviate)
DEPARTMENT / AGENCY / OFFICE / COMPANY (Write in full/Do not abbreviate)
MONTHLY SALARY
From
To
August 2015
March 2016
Teacher
Dominican Academy
P7,000
June 2016
January 2017
Clerk
Tokai Rika Philippines(Toyota)
P11,000
May 2017
up to present
Clerk
F' Tech Phillipines
P12,000
(Continue on separate sheet if necessary)
SIGNATURE
DATE
SALARY/ JOB/ PAY GRADE (if applicable)& STEP (Format "00-0")/ INCREMENT
LICENSE (if applicable) NUMBER
Date of Validity
1362070
02/05/2021
GOV'T SERVICE STATUS OF APPOINTMENT (Y/ N)
January 22, 2019 CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S 29.
INCLUSIVE DATES
NAME & ADDRESS OF ORGANIZATION (Write in full)
From
(mm/dd/yyyy) To
POSITION / NATURE OF WORK
NUMBER OF HOURS
(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) Type of LD
INCLUSIVE DATES OF ATTENDANCE 30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS (Write in full)
(mm/dd/yyyy)
( Managerial/ CONDUCTED/ SPONSORED BY NUMBER OF HOURS Supervisory/ (Write in full) Technical/etc )
From
To
How To Be A Values Based Teacher
10/4/2011
10/4/2011
8hours
PUP Unisan
Empowering Mentors in the K-12 Curriculum
3/23/2013
3/23/2013
8hours
PUP Unisan
Updates nd Trends in Education
10/6/2013
10/6/2013
8hours
PUP Unisan
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION 31.
SPECIAL SKILLS and HOBBIES
32.
NON-ACADEMIC DISTINCTIONS / RECOGNITION (Write in full)
(Continue on separate sheet if necessary)
33.
MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full)
SIGNATURE
DATE
January 22, 2019
ATION/S POSITION / NATURE OF WORK
anagerial positions)
DUCTED/ SPONSORED BY (Write in full)
PUP Unisan PUP Unisan PUP Unisan
MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full)
January 22, 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? b. within the fourth degree (for Local Government Unit - Career Employees)?
YES
✘
NO
YES
✘
NO
If YES, give details: ________________________________ 35.
a. Have you ever been found guilty of any administrative offense?
YES
NO
✘
If YES, give details: ________________________________ ________________________________ YES
b. Have you been criminally charged before any court?
✘
NO
If YES, give details: ________________________________ ________________________________ Date Filed: Status of Case/s: 36.
37.
38.
39.
Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal?
Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in the public or private sector?
YES
✘
NO
If YES, give details: ________________________________ ________________________________ YES
✘
NO
If YES, give details: ________________________________ ________________________________
a. Have you ever been a candidate in a national or local election held within the last year (except Barangay election)?
YES
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?
YES
✘
NO
✘
NO
✘
NO
YES
✘
NO
YES
✘
NO
✘
NO
If YES, give details: If YES, give details:
Have you acquired the status of an immigrant or permanent resident of another country?
YES
If YES, give details (country): 40.
a.
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: Are you a member of any indigenous group?
If YES, please specify: b.
Are you a person with disability?
If YES, please specify ID No: c.
Are you a solo parent?
YES
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 3.5 cm. X 4.5 cm (passport size) With full and handwritten name tag and signature over printed name
42.
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.
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
ID/License/Passport No.:
1362070
Signature (Sign inside the box)
Date/Place of Issuance:
Manila
Date Accomplished
SUBSCRIBED AND SWORN to before me this
Right Thumbmark
, affiant exhibiting his/her validly issued government ID as indicated above.
Person Administering Oath CS FORM 212 (Revised 2017), Page 4 of 4
Page 4 of 4
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
Amparo
2. SURNAME FIRST NAME
Lalaine
MIDDLE NAME
Galang
NAME EXTENSION (JR., SR)
3. DATE OF BIRTH (mm/dd/yyyy)
2/5/1994
16. CITIZENSHIP
✘
Filipino
Dual Citizenship by birth
Unisan, Quezon
4. PLACE OF BIRTH
Male
5. SEX 6 CIVIL STATUS
✘
Single Widowed Other/s:
7. HEIGHT (m)
160m
8. WEIGHT (kg)
50kg
9.
✘
Female
please indicate the details.
Married 17. RESIDENTIAL ADDRESS Separated
by naturalization
Pls. indicate country:
If holder of dual citizenship,
Philippines House/Block/Lot No. J.B Village Subdivision/Village Sta. Rosa City/Municipality
ZIP CODE
Street Balibago Barangay Laguna Province 4026
18. PERMANENT ADDRESS
BLOOD TYPE
House/Block/Lot No.
Street Almacen
10. GSIS ID NO. 11. PAG-IBIG ID NO.
1211-5338-0174
12. PHILHEALTH NO.
08-051476883
13. SSS NO.
04-3566765-2
19. TELEPHONE NO.
971-293-000
20. MOBILE NO.
14. TIN NO.
Barangay Quezon
City/Municipality
Province
4305
ZIP CODE
15. AGENCY EMPLOYEE NO.
Subdivision/Village Unisan
09076960830
[email protected]
21. E-MAIL ADDRESS (if any)
II. FAMILY BACKGROUND 22.
SPOUSE'S SURNAME
23. NAME of CHILDREN (Write full name and list all)
DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME MIDDLE NAME OCCUPATION EMPLOYER/BUSINESS NAME BUSINESS ADDRESS TELEPHONE NO. 24.
25.
FATHER'S SURNAME
Amparo
FIRST NAME
Ricardo
MIDDLE NAME
De Guzman
NAME EXTENSION (JR., SR)
MOTHER'S MAIDEN NAME SURNAME
Galang
FIRST NAME
Eulalia
MIDDLE NAME
Trinidad
(Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND 26.
NAME OF SCHOOL LEVEL
(Write in full)
BASIC EDUCATION/DEGREE/COURSE (Write in full)
PERIOD OF ATTENDANCE
HIGHEST LEVEL/ YEAR UNITS GRADUATED EARNED (if not graduated)
NAME OF SCHOOL LEVEL
(Write in full)
ELEMENTARY SECONDARY / VOCATIONAL
TRADE COURSE COLLEGE
BASIC EDUCATION/DEGREE/COURSE (Write in full) From
To
Almacen Elementary School
June 2001
March 2006
Leonarda De Vera Cruz National High School
June 2006
March 20010
June 2010
March 2014
Polytechnic University of the Philippines(Unisan Branch)
Bachelor of Science in Elementary Education
HIGHEST LEVEL/ YEAR UNITS GRADUATED EARNED (if not graduated)
GRADUATE STUDIES
(Continue on separate sheet if necessary)
SIGNATURE
DATE
January 22, 2019 CS FORM 212 (Revised 2017), Page 1 of
son concerned.
t fill up. For CSC use only)
ON (JR., SR)
naturalization
t go ay
a ce
t
en
ay n
ce
OF BIRTH (mm/dd/yyyy)
SCHOLARSHIP/ ACADEMIC HONORS RECEIVED
SCHOLARSHIP/ ACADEMIC HONORS RECEIVED
2, 2019
2 (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(LET)
RATING (If Applicable)
DATE OF EXAMINATION / CONFERMENT
PLACE OF EXAMINATION / CONFERMENT
77.40%
3/29/2015
Lucena 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 (mm/dd/yyyy)
POSITION TITLE (Write in full/Do not abbreviate)
DEPARTMENT / AGENCY / OFFICE / COMPANY (Write in full/Do not abbreviate)
MONTHLY SALARY
From
To
August 2015
March 2016
Teacher
Dominican Academy
P7,000
June 2016
January 2017
Clerk
Tokai Rika Philippines(Toyota)
P11,000
May 2017
up to present
Clerk
F' Tech Phillipines
P12,000
(Continue on separate sheet if necessary)
SIGNATURE
DATE
SALARY/ JOB/ PAY GRADE (if applicable)& STEP (Format "00-0")/ INCREMENT
LICENSE (if applicable) NUMBER
Date of Validity
1362070
02/05/2021
GOV'T SERVICE STATUS OF APPOINTMENT (Y/ N)
January 22, 2019 CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S 29.
INCLUSIVE DATES
NAME & ADDRESS OF ORGANIZATION (Write in full)
From
(mm/dd/yyyy) To
POSITION / NATURE OF WORK
NUMBER OF HOURS
(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) Type of LD
INCLUSIVE DATES OF ATTENDANCE 30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS (Write in full)
(mm/dd/yyyy)
( Managerial/ CONDUCTED/ SPONSORED BY NUMBER OF HOURS Supervisory/ (Write in full) Technical/etc )
From
To
How To Be A Values Based Teacher
10/4/2011
10/4/2011
8hours
PUP Unisan
Empowering Mentors in the K-12 Curriculum
3/23/2013
3/23/2013
8hours
PUP Unisan
Updates nd Trends in Education
10/6/2013
10/6/2013
8hours
PUP Unisan
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION 31.
SPECIAL SKILLS and HOBBIES
32.
NON-ACADEMIC DISTINCTIONS / RECOGNITION (Write in full)
(Continue on separate sheet if necessary)
33.
MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full)
SIGNATURE
DATE
January 22, 2019
ATION/S POSITION / NATURE OF WORK
anagerial positions)
DUCTED/ SPONSORED BY (Write in full)
PUP Unisan PUP Unisan PUP Unisan
MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full)
January 22, 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? b. within the fourth degree (for Local Government Unit - Career Employees)?
YES
✘
NO
YES
✘
NO
If YES, give details: ________________________________ 35.
a. Have you ever been found guilty of any administrative offense?
YES
NO
✘
If YES, give details: ________________________________ ________________________________ YES
b. Have you been criminally charged before any court?
✘
NO
If YES, give details: ________________________________ ________________________________ Date Filed: Status of Case/s: 36.
37.
38.
39.
Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal?
Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in the public or private sector?
YES
✘
NO
If YES, give details: ________________________________ ________________________________ YES
✘
NO
If YES, give details: ________________________________ ________________________________
a. Have you ever been a candidate in a national or local election held within the last year (except Barangay election)?
YES
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?
YES
✘
NO
✘
NO
✘
NO
YES
✘
NO
YES
✘
NO
✘
NO
If YES, give details: If YES, give details:
Have you acquired the status of an immigrant or permanent resident of another country?
YES
If YES, give details (country): 40.
a.
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: Are you a member of any indigenous group?
If YES, please specify: b.
Are you a person with disability?
If YES, please specify ID No: c.
Are you a solo parent?
YES
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 3.5 cm. X 4.5 cm (passport size) With full and handwritten name tag and signature over printed name
42.
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.
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
ID/License/Passport No.:
1362070
Signature (Sign inside the box)
Date/Place of Issuance:
Manila
Date Accomplished
SUBSCRIBED AND SWORN to before me this
Right Thumbmark
, affiant exhibiting his/her validly issued government ID as indicated above.
Person Administering Oath CS FORM 212 (Revised 2017), Page 4 of 4
Page 4 of 4
More Documents from "Lalaine Amparo"
Pds.xls
June 2020 6
Type Iv Hypersensitivity
May 2020 19
Induction Therapy
May 2020 18