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.
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 OCTAVIANO
N/A
FIRST NAME HIPOLITA

MIDDLE NAME RAMOS

3. DATE OF BIRTH
(mm/dd/yyyy) 12/9/1969 16. CITIZENSHIP ✘ Filipino Dual Citizenship
✘ by birth by
4. PLACE OF BIRTH POZORRUBIO, PANGASINAN If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS

Widowed Separated House/Block/Lot No. S

Other/s:
40 MAL
Subdivision/Village Ba
7. HEIGHT (m) 1.65 POZORRUBIO PANG
City/Municipality Pr
8. WEIGHT (kg) 60 ZIP CODE 2435

18. PERMANENT ADDRESS

9. BLOOD TYPE B
House/Block/Lot No. S
CASANFE
10. GSIS ID NO. CRN-006-0107-8385-8
Subdivision/Village Ba
POZORRUBIO
11. PAG-IBIG ID NO. 1280-0046-8471
City/Municipality Pr

12. PHILHEALTH NO. 19-000577415-6 ZIP CODE 2435

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

14. TIN NO. 187-036-862 20. MOBILE NO. 09107221328

15. AGENCY EMPLOYEE NO. 4117611 21. E-MAIL ADDRESS (if any) N/A

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME OCTAVIANO 23. NAME of CHILDREN (Write full name and list all)
N/A EAROL CHRISTIAN P. DUCUSIN
FIRST NAME MELCHOR

MIDDLE NAME GIPIT

OCCUPATION FARMING

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. 9275043652

24. FATHER'S SURNAME RAMOS

N/A
FIRST NAME PASTOR
 MIDDLE NAME SALCEDO

25. MOTHER'S MAIDEN NAME

SURNAME RAMOS

FIRST NAME FELOMINA

NAME OF SCHOOL
MIDDLE NAME (Continue on separate sheet if necessary
(Write in full)
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 PALACPALAC ELEMENTARY SCHOOL PRIMARY EDUCATION 1982 1988 GRADUATED

SECONDARY /
VOCATIONAL SAINT PHILOMENAS ACADEMY HIGH SCHOOL 1988 1992 GRADUATED

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

TRADE DON MARIANO MARCOS MEMORIAL
BACHELOR IN ELEMENTARY
COURSE
COLLEGE STATE UNIVERSITY-SOUTHERN LA 1992 1997 GRADUATED
EDUCATION
UNION CAMPUS
POLYTECHNIC COLLEGE OF LA
GRADUATE STUDIES MASTER OF ARTS IN EDUCATION 2012 2017 33 UNITS
UNION
(Continue on separate sheet if necessary)

SIGNATURE DATE
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)

N/A

Dual Citizenship

by naturalization

Pls. indicate country:

Street
MALOKIAT
Barangay
PANGASINAN
Province
2435

Street
CASANFERNANDOAN
Barangay
PANGASINAN
Province

N/A

09107221328

N/A

DATE OF BIRTH (mm/dd/yyyy)

12/22/1995
 (Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

FIFTH
1988
HONORS

1992 N/A

N/A N/A

1997 N/A

N/A 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 ap
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

(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

3/12/2016 PRESENT DEPARTMENT OF EDUCATION 250440 "

1/1/2016 3/11/2016 -DO- DEPARTMENT OF EDUCATION 247812 "

3/12/2013 12/31/2015 TEACHER II DEPARTMENT OF EDUCATION 239280 "

6/1/2012 3/11/2013 -DO- DEPARTMENT OF EDUCATION 233940 "

6/1/2011 5/31/2012 -DO- DEPARTMENT OF EDUCATION 218724 "

10/16/2010 5/31/2011 -DO- DEPARTMENT OF EDUCATION 203508 "

6/24/2010 10/15/2010 -DO- DEPARTMENT OF EDUCATION 200244 "

7/1/2009 6/23/2010 -DO- DEPARTMENT OF EDUCATION 184584 "

7/1/2008 6/30/2009 -DO- DEPARTMENT OF EDUCATION 159300 "

11/16/2007 6/30/2008 -DO- DEPARTMENT OF EDUCATION 144816 "

7/1/2007 11/15/2007 -DO- DEPARTMENT OF EDUCATION 141288 "

10/16/2004 6/30/2007 -DO- DEPARTMENT OF EDUCATION 128448 "

10/16/2001 10/15/2004 -DO- DEPARTMENT OF EDUCATION 125304 "

10/16/2001 10/15/2004 -DO- DEPARTMENT OF EDUCATION 125304 "

7/1/2001 10/15/2001 -DO- DEPARTMENT OF EDUCATION 122256 "

1/1/2000 6/30/2001 -DO- DEPARTMENT OF EDUCATION 116436 "

10/16/1998 12/31/2009 -DO- DEPARTMENT OF EDUCATION 105852 "

11/1/1997 10/15/1998 -DO- DEPARTMENT OF EDUCATION 103260 "

1/1/1997 10/31/1997 -DO- DEPARTMENT OF EDUCATION 87708 "

1/1/1996 12/31/1996 -DO- DEPARTMENT OF EDUCATION 72156.00 "

10/16/1995 12/31/1995 -DO- DEPARTMENT OF EDUCATION 58824 PERM.

8/31/1995 9/29/1995 -DO- DEPARTMENT OF EDUCATION 58824 "

8/1/1995 8/30/1995 TEACHER I DEPARTMENT OF EDUCATION 58824 SUBST.

SIGNATURE DATE
CS FORM 212 (Revised 20
 LICENSE (if applicable)

Date of
Validity

arate sheet if necessary)

GOV'T
SERVICE

(Y/
N)
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

N/A N/A N/A 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)
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

DIVISION LEDERSHIP TRAINING FOR SPG OFFICERS AND ADVISERS 1/6/2017 1/8/2017 24 HRS

DIVISION RE-ORIENTATION ON THE SCHOOL BASED FEEDING

9/22//16 8 HRS
PROGRAM(SBFP)2016-2017

MID-YEAR IN SERVICE TRAINING 10/24/2016 10/28/2017 24 HRS

DIVISION ORIENTATION CONFERRENCE OF SCHOOL CANTEEN TEACHER AND

8/12/2015 8 HRS
SCHOOL CANTEEN HELPER/AIDES

DIVISION TRAINING WORKSHOP ON EARLY CHILDHOOD EDUCATION 8/27/2015 8/29/2015 24 HRS

2ND DIVISION LEADERSHIP TRAINING SUREME PUPIL GOVERNMENT OFFICERS

9/8/2015 9/10/2015 24 HRS
AND ADVISERS
DIVISION TRAININGOF UN TRAINED TEACHERS FOR THE K TO 12 BASIC
9/26/2015 10/17/2015 24HRS
EDUCATION CURRICULUM (ELEMENTARY LEVEL)
2014DIVISION FOLLOW THROUGH TRAINING WORKSHOP ON CONDUCTING AND
6/27/2014 6/29/2014 24 HRS
MANAGING SCIENCE INVESTIGATORY PROJECT (CMSIP
2014 DIVISION YOUTH FOR ENVIRONMENT IN SCHOOL ORGANIZATION (YES-O)
11/7/2014 11/9/2014 24 HRS
CAMP AND LEADERSHIP TRAINING FOR THE ELEMENTARY LEVEL

DIVISION SEMINAR - WORKSHOP IN HOMEROOM GUIDANCE PROGRAM 9/26/2014 8 HRS

DISTRICT RE - ECHO TRAINING IN INCLUSIVE EDUCATION 5/31/2013 6/2/2014 24 HRS

PARALEGAL TRAINING AND ALTERNATIVE

6/13/2013 6/15/2013 24 HRS
DISPUTE RESOLUTION
DIVISION SUMMER TRAINING WORKSHOP
4/11/2013 4/11/2013 8 HRS
FOR GUIDANCE CONSELORS
SEMINAR WORKSHOP OF INFORMATION
AND COMMUNICATION AND TECHNOLOGY 10/25/2013 10/27/2013 24 HRS
FOR ELEM.TEACHERS
 (Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

N/A

(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)

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION
eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

N/A

eparate 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
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. 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
CASANFERNANDOAN,POZORRUBIO, the last 6 months
MODESTO B. DOCUSIN PANGASINAN
9293005476 3.5 cm. X 4.5 cm
(passport size)
CASANFERNANDOAN,POZORRUBIO,
GERLITA P. CARINO PANGASINAN
9175421468 With full and handwritten
name tag and signature over
PALACPALAC,POZORRUBIO,PANGASI printed name
DR. NEIL V. GAVINA NAN
9209698933
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: PROFESSIOAL REGULATION COMMISSION

ID/License/Passport No.:
Signature (Sign inside the box)

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