CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misrepretation 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
2. SURNAME TEJADA
NAME EXTENSION (JR., SR) N/A
FIRST NAME LORENA

MIDDLE NAME DELOS REYES

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 05/05/1980 ✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH SAN JACINTO, PANGASINAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS

Widowed Separated House/Block/Lot No. Street

LOBONG PROPER
Other/s:
Subdivision/Village Barangay
SAN JACINTO PANGASINAN
7. HEIGHT (m) 1.57 m
City/Municipality Province
8. WEIGHT (kg) 58 kg ZIP CODE 2431

18. PERMANENT ADDRESS

9. BLOOD TYPE O
House/Block/Lot No. Street
LOBONG PROPER
10. GSIS ID NO. 2004119210
Subdivision/Village Barangay
SAN JACINTO PANGASINAN
11. PAG-IBIG ID NO. 1030-0144-8069
City/Municipality Province

12. PHILHEALTH NO. 19-089913458-7 ZIP CODE 2431

13. SSS NO. 01-1544443-8 19. TELEPHONE NO. N/A

14. TIN NO. 927-988-487 20. MOBILE NO. 09092914450

15. AGENCY EMPLOYEE NO. 4196040 21. E-MAIL ADDRESS (if any) lorena.tejada@deped.gov.ph
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME TEJADA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME CRISTOPHER N/A CRISTINE LOUISE DELOS REYES TEJADA 02/06/2009

MIDDLE NAME GAMBOA CLAIRE LORAINE DELOS REYES TEJADA 03/01/2015

OCCUPATION TRICYCLE DRIVER

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME DELOS REYES

NAME EXTENSION (JR., SR)
FIRST NAME ELPIDIO N/A

MIDDLE NAME MORALES

25. MOTHER'S MAIDEN NAME

SURNAME VILLEGAS

FIRST NAME ERLINDA

MIDDLE NAME DE GUZMAN (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL HIGHEST LEVEL/
26. BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE UNITS YEAR
SCHOLARSHIP/
LEVEL (Write in ACADEMIC HONORS
(Write in full) EARNED GRADUATED
RECEIVED
full) (if not graduated)
From To
ELEMENTARY LABNEY ELEMENTARY SCHOOL PRIMARY EDUCATION 1987 1993 GRADUATED 1993 SALUTATORIAN

SECONDARY
VOCATIONAL / RIZAL NATIONAL HIGH SCHOOL BAGUIO CITY HIGH SCHOOL 1993 1997 GRADUATED 1997 N/A

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

TRADE
COURSE
COLLEGE UNIVERSITY OF THE CORDILLERAS BACHELOR OF ELEMENTARY EDUCATION 1999 2002 GRADUATED 2002 N/A

MASTER IN EDUCATION MAJOR IN

GRADUATE STUDIES LYCEUM NORTHWESTERN UNIVERSITY
MATHEMATICS
2014 2016 45 UNITS N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 26, 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 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 78% 08/25/2002 BAGUIO CITY 0807032 11/04/2003

(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
28. INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
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
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To
(Y/ N)
DEPARTMENT OF EDUCATION-PANGASINAN II
01/01/2017 PRESENT TEACHER I DIVISION-SAN JACINTO DISTRICT
P19,853.00 11 PERMANENT Y
DEPARTMENT OF EDUCATION-PANGASINAN II
01/01/2016 12/31/2016 TEACHER I DIVISION-SAN JACINTO DISTRICT
P19,286.00 11 PERMANENT Y
DEPARTMENT OF EDUCATION-PANGASINAN II
06/07/2014 12/31/2015 TEACHER I DIVISION-SAN JACINTO DISTRICT
P18,735.00 11 PERMANENT Y
DEPARTMENT OF EDUCATION-PANGASINAN II
06/01/2012 06/06/2014 TEACHER I DIVISION-SAN JACINTO DISTRICT
P18,549.00 11 PERMANENT Y
DEPARTMENT OF EDUCATION-PANGASINAN II
06/07/2011 05/31/2012 TEACHER I DIVISION-SAN JACINTO DISTRICT
P17,099.00 11 PERMANENT Y

(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 26, 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 / NATURE OF WORK
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/ SPONSORED BY
NUMBER OF HOURS
(Write in full) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To
DIV. TRAINING-WORKSHOP ON LIBRARY MANAGEMENT FOR ELEMENTARY LICENSED
12/21/2016 12/23/2016 24 TECHNICAL DEPARTMEN OF EDUCATION
LIBRARIANS AND TEACHER LIBRARIANS
SCHOOL BASED IN-SERVICE TRAINING ON UPDATING OF LEARNER PROFILES FOR END
04/13/2016 04/15/2016 24 TECHNICAL DEPARTMEN OF EDUCATION
OF YEAR (EOSY) 2015-2016

"TEACHER TRAINING: EFFECTIVE UTILIZATION OF EDUCATIONAL TELEVISION" 11/21/2015 11/25/2015 8 TECHNICAL ABS-CBN LINGKOD KAPAMILYA FOUNDATION

DIVISION SEMINAR-WORKSHOP ON HOMEROOM GUIDANCE PROGRAM 09/26/2014 09/26/2014 8 TECHNICAL DEPARTMEN OF EDUCATION

DISTRICT SEMINAR-WORKSHOP IN MUSIC FOR GRADE I AND II TEACHERS 04/21/2014 04/23/2014 24 TECHNICAL DEPARTMEN OF EDUCATION

DIVISION SEMINAR-WORKSHOP ON VALUES FORMATION AND MORAL RECOVERY

11/20/2013 11/22/2013 24 TECHNICAL DEPARTMEN OF EDUCATION
PROGRAM
2013 DIVISION YOUTH FOR ENVIRONMENT IN SCHOOLS ORGANIZATION (YES-O) CAMP
11/08/2013 11/10/2013 24 TECHNICAL DEPARTMEN OF EDUCATION
AND TRAINING
SCHOOL-BASED IN-SERVICE TRAINING ON ENHANCING INSTRUCTIONAL COMPETENCE
10/29/2013 10/31/2013 24 TECHNICAL DEPARTMEN OF EDUCATION
OF TEACHERS
SCHOOL-BASED IN-SERVICE TRAINING ON ENHANCING COMPETENCE IN TEACHING
07/25/2013 07/27/2013 24 TECHNICAL DEPARTMEN OF EDUCATION
CHILDREN WITH SPECIAL NEEDS
DIVISION TRAINING-WORKSHOP ON BASA, BEGINNING READING AND READING
07/22/2013 07/24/2013 24 TECHNICAL DEPARTMEN OF EDUCATION
AUGMENTATION DRIVE
COUNCIL FOR THE RESTORATION OF FILIPINO
"PUBLIC ACCOUNTABILITY AND ENHANCEMENT SEMINAR" 07/12/2013 07/13/2013 24 TECHNICAL
VALUES (CRFV)

DISTRICT RE-ECHO-TRAINING IN INCLUSIVE EDUCATION 06/21/2013 06/23/2013 24 TECHNICAL DEPARTMEN OF EDUCATION

DISTRICT TRAINING ON DIGITAL AND COMPUTER LITERACY 10/22/2012 10/24/2012 24 TECHNICAL DEPARTMEN OF EDUCATION

DIVISION SEMINAR ON MATHEMATICS TEACHING 10/19/2012 10/21/2012 24 TECHNICAL DEPARTMEN OF EDUCATION

DIVISION SEMINAR-WORKSHOP IN MTB-MLE 09/19/2012 09/22/2012 24 TECHNICAL DEPARTMEN OF EDUCATION

REGIONAL TRAINING FOR PRIVATE SCHOOLS GRADE I TEACHERS ON K TO 12 BASIC

06/06/2012 06/08/2012 24 TECHNICAL DEPARTMEN OF EDUCATION
EDUCATION CURRICULUM
DIVISION SEMINAR-WORKSHOP ON ENHANCING INSTRUCTIONAL COMPETENCE OF
01/21/2012 01/23/2012 24 TECHNICAL DEPARTMEN OF EDUCATION
ELEMENTARY MATHEMATICS TEACHER

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33. (Write
(Write in full)
in full)

COMPUTER LITERATE N/A SAN JACINTO DISTRICT TEACHERS CLUB

CROSS STITCHING

(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 26, 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 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
the last 6 months
DANIEL C. ABAOAG LOBONG, SAN JACINTO, PANGASINAN 09278758328 3.5 cm. X 4.5 cm
(passport size)
SAN GUILLERMO, SAN JACINTO,
AIDA A. QUILANG PANGASINAN
09276897552 With full and handwritten
name tag and signature over
printed name
MARIA P. BANDA LOBONG, SAN JACINTO, PANGASINAN
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete or photocopied picture
is not acceptable
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 PHOTO
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: PROFESSIONAL REGULATION COMMISSION

ID/License/Passport No.: 0807032

ID/License/Passport No.: 0807032
Signature (Sign inside the box)
APRIL 26, 2017
Date/Place of Issuance: 11/04/2003
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me thisAPRIL 26, 2017 , affiant exhibiting his/her validly issued government ID as indicated above.

DANIEL C. ABAOAG
Person Administering Oath

CS FORM 212 (Revised 2017), Page 4 of 4