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

MIDDLE NAME CAMBA

3. DATE OF BIRTH
(mm/dd/yyyy) 10/05/1995 16. CITIZENSHIP

4. PLACE OF BIRTH ECHAGUE, ISABLEA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX M

17. RESIDENTIAL ADDRESS PUROK 7

6 CIVIL STATUS Single
House/Block/Lot No. Street
PANGAL SUR
Subdivision/Village Barangay
ECHAGUE ISABELA
7. HEIGHT (m) 5`6
City/Municipality Province
8. WEIGHT (kg) 79 ZIP CODE 3309

18. PERMANENT ADDRESS PUROK 7

9. BLOOD TYPE O+
House/Block/Lot No. Street
PANGAL SUR
10. GSIS ID NO. N/A
Subdivision/Village Barangay
ECHAGUE ISABELA
11. PAG-IBIG ID NO. 121333859769
City/Municipality Province

12. PHILHEALTH NO. 06-201516289-9 ZIP CODE 3309

13. SSS NO. 01-3189565-0 19. TELEPHONE NO.

14. TIN NO. 359-774-491-000 20. MOBILE NO. 09972571491/09752238052

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

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME GADINGAN

SR
FIRST NAME ORLANDO

MIDDLE NAME COLLADO

25. MOTHER'S MAIDEN NAME CRISTOBAL

SURNAME GADINGAN

FIRST NAME FEBE

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

ELEMENTARY PANGAL SUR ELEMENTARY SCHOOL ELEMENTARY 2002 2008 GRADUATED 2008 N/A

SECONDARY
VOCATIONAL / PANGAL SUR HIGH SCHOOL SECONDARY 2008 2012 GRADUATED 2012 N/A

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

TRADE
COURSE
COLLEGE ISABELA STATE UNIVERSITY- JONES CAMPUS BACHELOR OF ELEMENTARY EDUCATION 2015 2019 GRADUATED 2019 N/A

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE 01/29/2024

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 77.8 01/30/2022 CAUAYAN CITY 1898805 10/05/2025

(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)

09/20/2022 06/06/2023 VOLUNTEER TEACHER PANGAL SUR HIGH SCHOOL N/A 0-0 VOLUNTEER 0
 (Continue on separate sheet if necessary)

SIGNATURE DATE 01/29/2024

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) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

SCHOOL LEARNING ACTION CELL 06/02/2023 8.0 TECHNICAL DEPED

SCHOOL LEARNING ACTION CELL 05/31/2023 8.0 TECHNICAL

DEPED

SCHOOL LEARNING ACTION CELL 02/28/2023 8.0 TECHNICAL

DEPED

SCHOOL BASED IN SERVICE TRAINING (INSET) 02/08/2023 02/10/2023 16.0 TECHNICAL

DEPED

SOUTH IN SERVICE TRAINING (INSET) 02/06/2023 02/07/2023 8.0 TECHNICAL

DEPED

SCHOOL LEARNING ACTION CELL 04/14/2023 8.0 TECHNICAL

DEPED

SCHOOL LEARNING ACTION CELL 12/09/2022 8.0 TECHNICAL

DEPED

(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)

COMPUTER LITERATE N/A N/A

ARTS DESIGNING N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 01/29/2024

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:
REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)
41.

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
JUN G. FLORES PANGAL SUR, ECHAGUE, ISABELA 9064896602 3.5 cm. X 4.5 cm
(passport size)

ROGELIO PALACAY PANGAL SUR, ECHAGUE, ISABELA 9171526757 With full and handwritten
name tag and signature over
printed name
DEBELYN R. DIRON PANGAL SUR, ECHAGUE, ISABELA 9564358430
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 09
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.: 1898805
Signature (Sign inside the box)

Date/Place of Issuance: 04-19-2022

Date Accomplished Right Thumbmark

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

JUN G. FLORES
Person Administering Oath

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