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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 SENINING
NAME EXTENSION (JR., SR
FIRST NAME REMEDIOS

MIDDLE NAME DUERO


3. DATE OF BIRTH
(mm/dd/yyyy) 6/3/1991 16. CITIZENSHIP
✘ Filipino Dual Citizenship
✘ by birth by
4. PLACE OF BIRTH TACLOBAN CITY If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male ✘ Female

Single ✘ Married 17. RESIDENTIAL ADDRESS


6 CIVIL STATUS
Widowed Separated House/Block/Lot No. S
SAN
Other/s:
Subdivision/Village Ba
PINTUYAN SOUTHE
7. HEIGHT (m) 147 cm.
City/Municipality Pr
8. WEIGHT (kg) 51 kgs. ZIP CODE 6614

18. PERMANENT ADDRESS


9. BLOOD TYPE O+
House/Block/Lot No. S
SAN
10. GSIS ID NO. 0203 8512 0288 4840
Subdivision/Village Ba
PINTUYAN SOUTHE
11. PAG-IBIG ID NO. NONE
City/Municipality Pr

12. PHILHEALTH NO. 13 000110454 4 ZIP CODE 6614

13. SSS NO. N/A 19. TELEPHONE NO. N/A

14. TIN NO. 444- 328 -260 20. MOBILE NO. 09489158168

15. AGENCY EMPLOYEE NO. 77060391 21. E-MAIL ADDRESS (if any) remzduero80@yahoo.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME SENINING 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME JONATHAN N/A

MIDDLE NAME LABASTIDA

OCCUPATION SELF - EMPLOYED

EMPLOYER/BUSINESS NAME JBS PURIFIED WATER REFILLING STATION

BUSINESS ADDRESS TACLOBAN CITY

TELEPHONE NO. N/A

24. FATHER'S SURNAME DUERO (DECEASED)

FIRST NAME MANUEL

MIDDLE NAME OLAER

25. MOTHER'S MAIDEN NAME

SURNAME DOTAROT

FIRST NAME NELMIE

MIDDLE NAME DAPO (Continue on separate sheet if necessary

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)
From To

ELEMENTARY PINTUYAN CENTRAL SCHOOL ELEMENTARY 1997 2003 GRADUATED

PINTUYAN NATIONAL VOCATIONAL HIGH


SECONDARY
SCHOOL
SECONDARY 2003 2007 GRADUATED
VOCATIONAL /

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


TRADE
COURSE BACHELOR OF SCIENCE IN INDUSTRIAL
COLLEGE EASTERN VISAYAS STATE UNIVERSITY
EDUCATION - CTRA
2007 2011 GRADUATED

SUMMER 2ND SEM.


GRADUATE STUDIES SOUTHERN LEYTE STATE UNIVERSITY MASTERS IN TECHNICAL EDUCATION
2015 2016-2017 27 units

(Continue on separate sheet if necessary)

SIGNATURE DATE 04/22/2019 CS FORM 212 (Re


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)

NAME EXTENSION (JR., SR)

Dual Citizenship

by naturalization

Pls. indicate country:

Street
SAN ROQUE
Barangay
SOUTHERN LEYTE
Province
6614

Street
SAN ROQUE
Barangay
SOUTHERN LEYTE
Province

6614

N/A

09489158168

remzduero80@yahoo.com

DATE OF BIRTH (mm/dd/yyyy)

N/A

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2003 N/A

2007 N/A
N/A N/A

2011 N/A

parate 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 applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity
LICENSURE EXAMINATION FOR TEACHERS
75% MARCH 2012 TACLOBAN CITY 1204588 ###
(LET)

(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. GOV'T
SERVICE
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 (Y/
N)
PINTUYAN NATIONAL VOCATIONAL REGULAR/
1/1/2019 PRESENT SECONDARY SCHOOL TEACHER II 22, 938.00 12/1 YES
HIGH SCHOOL PERMANENT
PINTUYAN NATIONAL VOCATIONAL REGULAR/
1/1/2018 12/31/2018 SECONDARY SCHOOL TEACHER II 22, 149.00 12/1 YES
HIGH SCHOOL PERMANENT
PINTUYAN NATIONAL VOCATIONAL REGULAR/
1/1/2017 12/31/2017 SECONDARY SCHOOL TEACHER II 21, 387.00 12/1 YES
HIGH SCHOOL PERMANENT
PINTUYAN NATIONAL VOCATIONAL REGULAR/
7/29/2016 12/31/2016 SECONDARY SCHOOL TEACHER II 20, 651.00 12/1 YES
HIGH SCHOOL PERMANENT
PINTUYAN NATIONAL VOCATIONAL REGULAR/
1/1/2016 7/28/2016 SECONDARY SCHOOL TEACHER I 19, 077.00 11/2 YES
HIGH SCHOOL PERMANENT
PINTUYAN NATIONAL VOCATIONAL REGULAR/
6/11/2013 12/31/2015 SECONDARY SCHOOL TEACHER I 18, 549.00 11/1 PERMANENT YES
HIGH SCHOOL

(Continue on separate sheet if necessary)

SIGNATURE DATE 04/03/2019 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 / N
From To

Pintuyan Town Founding Anniversary Celebration 10/20/2018 10/20/2018 8 hrs. Part

Tree Planting Activity 10/16/2018 10/16/2018 4 hrs. Part

Pintuyan Town Fiesta Celebration 9/29/2018 9/29/2018 4 hrs. Part

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

Orientation Workshop on the use of PPST Resource Package 11/16/2018 11/16/2018 8 hrs. District

Roll-out on RPMS Manual for Teachers and School Heads 10/3/2018 10/4/2018 12 hrs. District

Training Workshop on the Basic Literacy Program for Teachers on Photoshop Pintuyan Natio
12/2/2016 12/3/2016 16 hrs.
Manipulation and Application on Visual Basic Pintuyan, Sout
Pintuyan Natio
District Conference 10/29/2015 10/29/2015 8 hrs.
(PNHS) Pintuy

Civil Registration Seminar 11/22/2014 11/22/2014 4 hrs. District

Moral Values Formation Seminar 11/16/2014 11/16/2014 4 hrs. District

Teachers Induction Program 8/22/2014 8/24/2014 24 hrs. Division

TM Traning Level I 1/20/2014 2/13/2014 60 hrs. TESDA

Eastern Visayas Professionals Conference 8/25/2012 8/25/2012 8 hrs. PRC / FAPORE

Skills Enhancement Training and Assessment on Garment Trades 5/21/2012 5/31/2012 80 hrs. Tech. Voc.

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


MEMBERSH
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

Dressmaking/ Sewing Best in Clothing Textile Related Arts A


Teachers

(Continue on separate sheet if necessary)

SIGNATURE DATE 04/03/2019


EOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

Participant

Participant

Participant

te sheet if necessary)

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

CONDUCTED/ SPONSORED BY
(Write in full)

District

District

Pintuyan National Vocational High School


Pintuyan, Southern Leyte (DepEd)
Pintuyan National High School Pintuyan,
(PNHS) Pintuyan, Southern Leyte

District

District

Division

TESDA

PRC / FAPORE

Tech. Voc.

te sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION

(Write in full)

Alumni Association
Teachers and Employees Association

te sheet if necessary)

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 NO
YES ✘
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
SAN JUAN, PINTUYAN SOUTHERN the last 6 months
RICO L. AMPER LEYTE
917777317 3.5 cm. X 4.5 cm
(passport size)
STA. CRUZ, PINTUYAN, SOUTHERN
NEMESIO L. AMPER LEYTE
9565495423 With full and handwritten
name tag and signature over
SAN ROQUE, PINTUYAN, SOUTHERN printed name
JOSEPHINE M. MADRID LEYTE 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
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

ID/License/Passport No.: 1204588


Signature (Sign inside the box)
04/ 03/ 2019
Date/Place of Issuance: 10/31/2012 / Tacloban City
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 of


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