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 MARTINEZ
NAME EXTENSION (JR., SR
FIRST NAME MARLON

MIDDLE NAME CANLAS

3. DATE OF BIRTH
(mm/dd/yyyy) 10/21/1987 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH BAGONG SILANG, CALOOCAN 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

Other/s:
Subdivision/Village Ba
7. HEIGHT (m) 1.68 M
City/Municipality Pr
8. WEIGHT (kg) 67 KGS. ZIP CODE

18. PERMANENT ADDRESS 2411 PH.8B, PKG. 4, BLK.14, LOT2 BAGON

9. BLOOD TYPE A
House/Block/Lot No. S

10. GSIS ID NO. 02004327102

Subdivision/Village Ba
CALOOCAN
11. PAG-IBIG ID NO. 1210-8998-5023
City/Municipality Pr

12. PHILHEALTH NO. 02-050452869-4 ZIP CODE 1421

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

14. TIN NO. 268-646-535 20. MOBILE NO. 09266324363

15. AGENCY EMPLOYEE NO.
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME
FIRST NAME
4696684 21. E-MAIL ADDRESS (if any) marlon.martinez21@deped.go
MARTINEZ 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
CATHERINE MARL JOHANN T. MARTINEZ

MIDDLE NAME TAPERLA MITHRIL CAIN T. MARTINEZ

OCCUPATION TEACHER

EMPLOYER/BUSINESS NAME DEPED CALOOCAN - LLANO HIGH SCHOOL

BUSINESS ADDRESS 10TH AVE. GRACE PARK, CALOOCAN CITY

TELEPHONE NO. N/A

24. FATHER'S SURNAME MARTINEZ

FIRST NAME AVELINO JR.

 MIDDLE NAME RETODO

25. MOTHER'S MAIDEN NAME

SURNAME CANLAS

FIRST NAME LEONIDA

MIDDLE NAME TAYO (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 STAR ELEMENTARY SCHOOL 6/3/1995 3/30/2000

SECONDARY
VOCATIONAL / BAGONG SILANG HIGH SCHOOL 6/5/2000 3/30/2004

THE SALVATION ARMY CHILD CARE LEARNING

CENTER
BASIC ELECTRONICS AND ELECTRICALS 6/7/2003 3/30/2004

TRADE
COURSE BACHELOR OF SCIENCE IN ELEMENTARY
COLLEGE UNIVERSITY OF CALOOCAN CITY
EDUCATION
6/4/2004 4/18/2008

MASTERS OF EDUCATION MAJOR IN

GRADUATE STUDIES UNIVERSITY OF CALOOCAN CITY
EDUCATIONAL MANAGEMENT
6/7/2016 PRESENT 18 UNITS
(Continue on separate sheet if necessary)

SIGNATURE DATE Novemb

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)

NAME EXTENSION (JR., SR)

Dual Citizenship

by naturalization

Pls. indicate country:

Street

Barangay

Province

BAGONG SILANG
Street
176
Barangay
METRO MANILA
Province

N/A

09266324363

marlon.martinez21@deped.gov.ph

DATE OF BIRTH (mm/dd/yyyy)

10/1/2013

12/26/2018
 (Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2000

2004

2004

2008

parate sheet if necessary)

November 11, 2019

CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable)
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

J. P. RIZAL ELEMENTARY SCHOOL / PRITIL,

PRC - BOARD OF PROFESSIONAL TEACHERS 80.8 9/28/2008
TONDO, MANILA

(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
(Write in full/Do not (Write in SALARY
applicable)& STEP
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To

CALOOCAN NORTH ELEMENTARY

4/15/2013 PRESENT TEACHER 1 19077.00 11-2
SCHOOL
HOLY ANGEL SCHOOL OF CALOOCAN,
6/1/2009 3/31/2013 GS FACULTY MEMBER 10000.00
INC.
BLOOMINGTON MIDDLE AND GRADE
6/1/2008 3/31/2009 SCHOOL SECRETARY 6500.00
SCHOOL
 (Continue on separate sheet if necessary)

SIGNATURE DATE NOVEMBER 11, 2

CS FORM 212
 LICENSE (if applicable)

NUMBER Date of
Validity

1101601 10/21/2018

ue on separate sheet if necessary)

n of duties should be indicated in the attached Work Experience sheet. GOV'T

SERVICE

STATUS OF
APPOINTMENT

(Y/
N)
ORIGINAL Y
CONTRACTU
N
AL
CONTRACTU
N
AL
ue on separate sheet if necessary)

NOVEMBER 11, 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 /
From To
ST. JOSEPH FOUNDATION FOR CHILDRESN AND AGIN, INC. / PH.7B, PKG. 10,
3/24/2007 5/27/2007 200 BAND INSTRUCTOR
BAGONG SILANG, CALOOCAN CITY

(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
MAPEH Division Learning Action Cell Session on Identifying Critical Content in Music, Arts,
11/09/2018 11/09/2018 8 Supervisory Schools Divisio
Physical Education and Health and MAPEH Contextualization Process
Department of
National Training in Sports Coaching (Developmental Level) 10/22/2018 10/26/2018 40 Managerial
Services

Coaches Clinic of Jr. NBA Philippines 2018 05/18/2018 05/18/2018 8 Jr. NBA and Al

Summative Assessment 09/15/2017 09/15/2017 8 Supervisory Schools Divisio

Division Mass Training of Grade 6 Teachers on the Implementation of the K to 12 Curriculum 8/5/2017 05/13/2017 40 Schools Divisio

Equipping the Trainers of Leaders for the 21st Century 3/8/2016 3/8/2016 8 Technical Caloocan Nort

Division Mass Training of Grade 4 Teachers on the Implementation of the K to 12 Curriculum 10/5/2015 05/16/2015 40 Schools Divisio

Professionalism and Dealing with Outsiders' Perception 05/26/2014 05/26/2014 8 Supervisory Rex Bookstore
 (Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

INSTRUMENTALIST Electronic Technician

(Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

BAND INSTRUCTOR

eparate sheet if necessary)

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

CONDUCTED/ SPONSORED BY
(Write in full)

Schools Division office - Caloocan City

Department of Education Bureau of Learner Support

Services

Jr. NBA and Alaska

Schools Division office - Caloocan City

Schools Division office - Caloocan City

Caloocan North District I

Schools Division office - Caloocan City

Rex Bookstore
eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

eparate sheet if necessary)

November 11, 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. 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
ST. ANNE DECA HOMES, MARILAO, the last 6 months
LEOBEN FERNANDEZ BULACAN
9486175692 3.5 cm. X 4.5 cm
(passport size)
PH. 9, PKG. 2, BAGONG SILANG,
RAINIER VINCENT BONIFACIO CALOOCAN CTIY
9054564181 With full and handwritten
name tag and signature over
PH. 8B, PKG. 3, BLK. 14, LOT 2, printed name
JHUN ROMMEL ESGUERRA BAGONG SILANG, CALOOCAN CITY
9192343354
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: PRC

ID/License/Passport No.: 1101601

Signature (Sign inside the box)
11/11/2019
Date/Place of Issuance: 7/1/2015 - Sampaloc, Manila
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