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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 case/s aga
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

I. PERSONAL INFORMATION
2. SURNAME Teneza

FIRST NAME Mario

MIDDLE NAME Biralde


3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 4/21/1967 Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH Quezon City If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male Female

6 CIVIL STATUS Single Married 17. RESIDENTIAL ADDRESS 28 Planas Site C


Widowed Separated House/Block/Lot No. S
Other/s:
Kau
Subdivision/Village Bar
Quezon City N
7. HEIGHT (m) 165m
City/Municipality Pr
8. WEIGHT (kg) 55 ZIP CODE

18. PERMANENT ADDRESS 28 Planas Site C


9. BLOOD TYPE B
House/Block/Lot No. S
Kau
10. GSIS ID NO. 109560273125
Subdivision/Village Bar
Quezon City N
11. PAG-IBIG ID NO. 0001-110489-09
City/Municipality Pro
12. PHILHEALTH NO. 190005384501 ZIP CODE 1119

13. SSS NO. 33-3277966-6 19. TELEPHONE NO. 4486672

14. TIN NO. 167-300-581 20. MOBILE NO. 09151770598

15. AGENCY EMPLOYEE NO. 5368296 21. E-MAIL ADDRESS (if any) mariobteneza@yahoo.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME Teneza 23.NAME of CHILDREN (Write full name and list all)

FIRST NAME Segundina Marcus Angelo V. Teneza

MIDDLE NAME Villlanueva Marion Dominic V. Teneza

OCCUPATION Dentist III Marius Benedic V. Teneza

EMPLOYER/BUSINESS NAME Quezon City Health Department Mariane Klare V. Teneza

BUSINESS ADDRESS Ermin Garcia Cubao Quezon City Martin Elijah

TELEPHONE NO. 4486672

24. FATHER'S SURNAME Teneza

FIRST NAME Marcos

MIDDLE NAME Tordil

25. MOTHER'S MAIDEN NAME Flordelina M. Biralde

SURNAME Teneza

FIRST NAME Flordelina

MIDDLE NAME Biralde


III. EDUCATIONAL BACKGROUND
NAME OF SCHOOL HIGHEST LEVEL/
26. BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE UNITS
LEVEL (Write in EARNED
(Write in full)
full) (if not graduated)
NAME OF SCHOOL HIGHEST LEVEL/
BASIC EDUCATION/DEGREE/COURSE UNITS
LEVEL (Write in EARNED
(Write in full)
full) (if not graduated)
From To

ELEMENTARY P. Bernardo Elem. School Elementary graduate 1970 1979

SECONDARY /
VOCATIONAL P. Bernardo High. School High School graduate 1980 1984

TRADE
Bachelor of Human Behavior
COURSE
COLLEGE Polytechnic University of the Phil. 1985 1991
Technology
Master of Arts in Guidance
GRADUATE STUDIES Phil. Normal University 2007 2013
Counseling
(Continue on separate sheet if necessary)

SIGNATURE DATE April

CS FORM
L DATA SHEET
rience 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)

Dual Citizenship

by naturalization

Pls. indicate country:

Cubao
Street
Kaunlaran
Barangay
NCR
Province

Cubao
Street
Kaunlaran
Barangay
NCR
Province
1119

4486672

09151770598

mariobteneza@yahoo.com

DATE OF BIRTH (mm/dd/yy)

11/19/1996

9/26/2000

11/9/2002

2/15/2004

5/6/2007

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED
SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

Graduate

Graduate

Graduate

parate sheet if necessary)

April 21,2017

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

National Board Examination for Teacher 11/10/1991 Quezon City

CS Professional Examination 84.3 7/30/1989 Quezon City

CS Sub-Professional Examination 71.5 8/3/1987 Caloocan

(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

5-15-'1986 9-7-'1989 Emergency Employee Division of City Schools Contractual

8-12-'1989 5-17-'1991 Temporary Guidance Counselor Camp Gen. E. Aguinaldo H.S. Contractual

5-22-'1991 10-15-'1998 Territory Salesmanager Gillette Phils. Inc. Permanent

8-12-'1999 present Guidance Counselor III R. Magsaysay (Cubao) H.S. Permanent


(Continue on separate sheet if necessary)

SIGNATURE DATE May 4, 2017


CS FORM 212 (Revised 20
LICENSE (if applicable)

Date of
Validity

arate sheet if necessary)

GOV'T
SERVICE

(Y/
N)
arate sheet if necessary)

May 4, 2017
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 /
From To

Cathedral Tribunal Court 11/12/2016 present Pre-Jud

Knight of Colombus 10/12/2000 present m

Parish Ministry on Family and Life (PMFL) 9/16/2003 present m

Parish Renewal Experience (Prex) 12/4/2007 present Se

Rotary Club (Mid-town) Cubao 8/17/2012 present m

(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/
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To

(Continue on separate sheet if necessary)


VIII. OTHER INFORMATION
MEMBERS
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

(Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

Pre-Judicial Counselor

member

member

Secretariat

member

eparate sheet if necessary)


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

CONDUCTED/ SPONSORED BY
(Write in full)

eparate sheet if necessary)


MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

eparate sheet if necessary)

May 4, 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:

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAME ADDRESS TEL. NO.


ID picture taken within
the last 6 months
Rolando Portes 12 Planas Site Cubao Q.C. 825-17-22 3.5 cm. X 4.5 cm
(passport size)

Regino G. Cabana 9 Planas Site Cubao Q.C. 994-16-23 With full and handwritten
name tag and signature over
printed name
Roberto Garcia 18 Planas Site Cubao Q.C. 723-18-12
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:

ID/License/Passport No.:
Signature (Sign inside the box)
May 4, 2017
Date/Place of Issuance:
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 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