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 MORENO
NAME EXTENSION (JR., SR)
FIRST NAME ANGELA FAITH

MIDDLE NAME BANDIN

3. DATE OF BIRTH
(mm/dd/yyyy) 2/3/1999 16. CITIZENSHIP

4. PLACE OF BIRTH CALOOCAN CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX FEMALE

17. RESIDENTIAL ADDRESS #32 Bayabas Street

6 CIVIL STATUS
House/Block/Lot No. Street
Western Bicutan
Subdivision/Village Barangay
Taguig City
7. HEIGHT (m) 1.48
City/Municipality Province
8. WEIGHT (kg) 43 ZIP CODE 1630

18. PERMANENT ADDRESS #32 Bayabas Street

9. BLOOD TYPE
House/Block/Lot No. Street
Western Bicutan
10. GSIS ID NO. N/A
Subdivision/Village Barangay
Taguig City
11. PAG-IBIG ID NO. 921279916393
City/Municipality Province

12. PHILHEALTH NO. 0525-1603-2758 ZIP CODE 1630

13. SSS NO. 34-8984208-0 19. TELEPHONE NO. N/A

14. TIN NO. N/A 20. MOBILE NO. 09099505733

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 MORENO

NAME EXTENSION (JR., SR)
FIRST NAME SALVADOR

MIDDLE NAME CATAYNA

25. MOTHER'S MAIDEN NAME

SURNAME MORENO

FIRST NAME MARIA SALVE

MIDDLE NAME BANDIN (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
ELEMENTARY MANGATAREM II CENTRAL SCHOOL PRIMARY EDUCATION 2005 2011 N/A 2011 N/A

SECONDARY /
VOCATIONAL MANGATAREM NATIONAL HIGH SCHOOL SECONDARY EDUCATION 2011 2015 N/A 2015 N/A

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

TRADE
MYSTICAL ROSE COLLEGE OF SCIENCE AND
COURSE
COLLEGE
TECHNOLOGY
GENERAL EDUCATION 2015 2019 N/A 2019 N/A

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A

(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 79.0 9/29/2019 BAGUIO CITY 1811081 2/3/2025

(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
INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
28. 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)

7 25 2022 12 29 2022 Encoder Municipal Civil Registrar 6000.00

(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

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
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
TECHNICAL EDUCATION AND SKILLS DEVELOPMENT
BASIC COMPUTER LITERACY 6/5/2019 5/24/19 80.0 TECHNICAL
AUTHORITY

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

COMPUTER LITERACY N/A N/A

 (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)?

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

b. Have you been criminally charged before any court?

36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation

37. Have you ever been separated from the service in any of the following modes: resignation, retirem

38. a. Have you ever been a candidate in a national or local election held within the last year (except B

b. Have you resigned from the government service during the three (3)-month period before the la

39. Have you acquired the status of an immigrant or permanent resident of another country?

40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA 72

a. Are you a member of any indigenous group?

b. Are you a person with disability?

c. Are you a solo parent?

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

ANAM

MEM

ROGELI
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is
head/authorized representative to verify/validate the contents stated herein. I agree that any

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.) PLEASE INDICATE ID Number and D

Government Issued ID:

ID/License/Passport No:

Date/Place of Issuance:

SUBSCRIBED AND
onsanguinity or affinity to the appointing or recommending authority, or to the
fice or to the person who has immediate supervision over you in the Office,
nt where you will be apppointed,
gree?
egree (for Local Government Unit - Career Employees)?

en found guilty of any administrative offense?

iminally charged before any court?

convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal?

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 out (abolition) i

en a candidate in a national or local election held within the last year (except Barangay election)?

d from the government service during the three (3)-month period before the last election to promote/actively campaign for a national or local candidate?

he status of an immigrant or permanent resident of another country?

genous 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:

f any indigenous group?

th disability?

nt?

not related by consanguinity or affinity to applicant /appointee)

NAME

ANAMARIE VIOLENTA

MEMIA MENDOZA

ROGELIA Q. FERNANDEZ
h 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 regulati
resentative 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/crimi

Passport, GSIS, SSS, PRC, Driver's License, etc.) PLEASE INDICATE ID Number and Date of Issuance

PRC

1811081

12/18/2019 ROSALES,PANGASINAN

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued gove
 If YES, give details:
________________________________

If YES, give details:

________________________________
________________________________

If YES, give details:

________________________________
Date Filed:
________________________________
Status of Case/s:

If YES, give details:

________________________________
________________________________
contract or phased out (abolition) in the public or private sector?
If YES, give details:
________________________________
________________________________

If YES, give details:

e?
If YES, give details:

If YES, give details (country):

er the following items:

If YES, please specify:

If YES, please specify ID No:

If YES, please specify ID No:

ID picture taken within

ADDRESS TEL. NO.
the last 6 months
4.5 cm. X 3.5 cm
9062448250 (passport size)

9383268290 Computer generated

or photocopied picture
is not acceptable

pertinent laws, rules and regulations of the Republic of the Philippines. I authorize the agency
use the filing of administrative/criminal case/s against me.

PHOTO

Signature (Sign inside the box)

Date Accomplished Right Thumbmark

nt exhibiting his/her validly issued government ID as indicated above.

Person Administering Oath

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