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 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 CANDILANZA
NAME EXTENSION (JR., SR)
FIRST NAME IVY JESSA

MIDDLE NAME OMA-AN

3. DATE OF BIRTH
(mm/dd/yyyy) 12/10/996 16. CITIZENSHIP
✘

4. PLACE OF BIRTH SAN FERNANDO CEBU If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘

✘ 17. RESIDENTIAL ADDRESS PUROK DONA LUZ

6 CIVIL STATUS
House/Block/Lot No. Street
TINUBDAN
Subdivision/Village Barangay
SAN FERNANDO CEBU
7. HEIGHT (m) 149
City/Municipality Province
8. WEIGHT (kg) 65 ZIP CODE 6018

18. PERMANENT ADDRESS PUROK DONA LUZ

9. BLOOD TYPE B+
House/Block/Lot No. Street
TINUBDAN
10. GSIS ID NO. 2005610297
Subdivision/Village Barangay
SAN FERNANDO CEBU
11. PAG-IBIG ID NO. 121196099680
City/Municipality Province

12. PHILHEALTH NO. 120515542049 ZIP CODE 6018

13. SSS NO. 0639523987 19. TELEPHONE NO.

14. TIN NO. 341497350 20. MOBILE NO. 09291858448

15. AGENCY EMPLOYEE NO. 6090508 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME GABUTIN 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME JULEX

NAME EXTENSION (JR., SR)
DAMIEN GIL C. GABUTIN 2/11/2019

MIDDLE NAME LABUGA

OCCUPATION GRAPHIC DESIGNER

EMPLOYER/BUSINESS NAME TASKPRO INC.

BUSINESS ADDRESS CEBU CITY

TELEPHONE NO.

24. FATHER'S SURNAME CANDILANZA

NAME EXTENSION (JR., SR)
FIRST NAME RUBEN

MIDDLE NAME ALICAWAY

25. MOTHER'S MAIDEN NAME

SURNAME OMA-AN

FIRST NAME EVELYN

MIDDLE NAME TARUNGOY (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

SALUTATORIA
ELEMENTARY TINUBDAN ELEMENTARY SCHOOL ELEMENTARY 2003 2009 GRADUATED 2009 N

HONORABLE
SECONDARY /
VOCATIONAL NOTRE DAME ACADEMY JUNIOR HIGH SCHOOL 2009 2013 GRADUATED 2013 MENTION

TRADE
COURSE
COLLEGE CEBU NORMAL UNIVERSITY BSED-MAJOR IN PHYSICAL SCIENCES 2013 2017 GRADUATED 2017 CUM LAUDE

GRADUATE STUDIES CEBU TECHNOLOGICAL UNIVERSITY MAED- MAJOR IN TEACHING CHEMISTRY 2021 PRESENT 18 UNITS NA NA
(Continue on separate sheet if necessary)

SIGNATURE DATE
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 -LET 84.0 9/24/2017 UV-MAIN CAMPUS 17-627605 6/1/2027

(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
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)

3/4/2017 9/25/2017 ACADEMIC SPECIALIST GLOBAL SPEECH ACADEMIC CENTER 9000.00 22-1 CONTRACTUAL N

10/17/2017 05/30/2019 INTAKE COORDINATOR OPTUM GLOBAL SOLUTIONS 18500.00 22-1 CONTRACTUAL N

DEPED-CEBU PROVINCE- SOUTH

11/6/2019 PRESENT TEACHER 1 POBLACION NHS MATH AND SCIENCE 27000.00 11 PERMANENT Y
SCHOOL

(Continue on separate sheet if necessary)

SIGNATURE DATE
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

NA NA NA NA NA

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
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

(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 in
(Write in full)
full)

(Continue on separate sheet if necessary)

SIGNATURE DATE
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? ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? ✘

If YES, give details:

________________________________

35. a. Have you ever been found guilty of any administrative offense? ✘

If YES, give details:

________________________________
________________________________
b. Have you been criminally charged before any court? ✘

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 ✘
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, ✘
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 ✘
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last ✘
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? ✘

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? ✘
If YES, please specify:
b. Are you a person with disability? ✘
If YES, please specify ID No:
c. Are you a solo parent? ✘
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
ROCHIE G. VILLAMERO 4.5 cm. X 3.5 cm
(passport size)

NEDDIE V. JAMIL
Computer generated
or photocopied picture
is not acceptable

42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and
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 LICENSE

ID/License/Passport No.: 17-627-605

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 of 4