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 TIANSING
NAME EXTENSION (JR., SR)
FIRST NAME ROSELIE KLAIRE

MIDDLE NAME LAROA

3. DATE OF BIRTH
(mm/dd/yyyy) MAY/19/1996 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH KABANGKALAN,NEGROS OCCINDENTAL If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Female
Male ✘

17. RESIDENTIAL ADDRESS N/A Purok-2

6 CIVIL STATUS ✘ Single Married
House/Block/Lot No. Street
Widowed Separate
N/A Magdagooc
Other/s: d
Subdivision/Village Barangay
Jabonga Agusan del Norte
7. HEIGHT (m) 1.52
City/Municipality Province
8. WEIGHT (kg) 55 ZIP CODE 8607

18. PERMANENT ADDRESS N/A Purok-2

9. BLOOD TYPE O
House/Block/Lot No. Street
N/A Magdagooc
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A Jabonga Agusan del Norte

City/Municipality Province

12. PHILHEALTH NO. 182014367714 ZIP CODE 8607

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

14. TIN NO. N/A 20. MOBILE NO. 09355355133/09385791607

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
N/A
MIDDLE NAME N/A N/A
N/A
OCCUPATION N/A N/A
N/A
EMPLOYER/BUSINESS NAME N/A N/A
N/A
BUSINESS ADDRESS N/A N/A
N/A
TELEPHONE NO. N/A N/A
N/A
24. FATHER'S SURNAME TIANSING N/A
NAME EXTENSION (JR., SR) N/A
FIRST NAME JOSE EDWIN FELICITO N/A
N/A
MIDDLE NAME LAURENTE N/A
N/A
25. MOTHER'S MAIDEN NAME N/A
N/A
SURNAME LAROA N/A
N/A
FIRST NAME ANALYN N/A

MIDDLE NAME CATURAN (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY JUAN L. SUBRASTAS ELEM. SCHOOL PRIIMARY 2004 2009 GRADUATED 2009 6TH HONOR

SECONDARY MAGDAGOOC NATIONAL HIGH SCHOOL SECONDARY 2009 2013 GRADUATED 2013 6TH HONOR
VOCATIONAL /

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

TRADE
COURSE BACHELOR OF SECONDARY EDUCATION
COLLEGE NORTHERN MINDANAO COLLEGES INC. MAJOR IN FILIPINO 2013 2018 GRADUATED 2018 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 January 28,2025

CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY
27. LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER RATING DATE OF
SPECIAL LAWS/ CES/ CSEE (If Applicable) EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT NUMBER Date of
Validity

LICENSURE EXAMINATION FOR TEACHER 77.2 OCT. 2,2022 BUTUAN CITY 2045642 5/19/2026

(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
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY GRADE (if 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)

8/10/2024 11/25/2024 Substitute Teacher I Agusan del norte Division 28512.00 grade 11 CONTRACTUAL N/A

6/3/2019 6/3/2020 TEACHER SCHOOL ADMIN 1000.00 N/A MEMORAMDUM OF

AGREEMENT N/A

6/5/2018 6/5/2019 JOB ORDER LGU 2058.00 N/A CONTRACTUAL N/A

SIGNATURE DATE January 28,2025

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

(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
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE Type of LD
NUMBER OF HOURS
( Managerial/ CONDUCTED/ SPONSORED BY
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

DIVION INTREGATED STUDENTS ACTIVITY 10/1/2019 10/9/2019 8 Hours Technical SCHOOL DIVISION

DISTRICT TRAINING-WORLSHOP IN CAMPUS JOURNALISM 8/27/2019 8/29/2019 8 Hours Technical SCHOOL DISTRICT

INTER HIGH VOLLEYBALL TOURNAMENT 8/5/2019 8/6/2019 8 Hours Technical MUNICIPALITY

DISTRICT REORIENTATION ON RESULTS PERFORMANCE MANAGEMENT SYSTEM(RPMS) MANUAL FOR TEACHERS AND SCHOOL HEADS AND ORIENTATION
ON THE PHILIPPINE PROFESSIONAL STANDARD FOR TEACHERS(PPST) 7/20/2019 7/27/2019 8 Hours Technical SCHOOL DISTRICT

DIVISION SCHOOL PRES CONFERENCE 10/15/2018 10/18/2018 8 Hours Technical SCHOOL DISTRICT

DISTRICT ECHO-TRAINING ON RESULTS PERFORMANCE MANAGEMENT SYSTEM(RPMS) MANUAL FOR TEACHERS AND SCHOOL HEADS AND ORIENTATION ON
THE PHILIPPINES PROFESSIONALS STANDARD FOR TEACHERA(PPST) 8/28/2018 8/20/2018 8 Hours Technical SCHOOL DISTRICT

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE January 28,2025

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
by any court or tribunal? YES ✘ NO
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 YES ✘ NO
out (abolition) in the public or private sector? If YES, give details:
________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? YES ✘ NO
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
Anacleto A. Larano, Jr. Libas, Jabonga, Agusan del norte 9088944402 3.5 cm. X 4.5 cm
(passport size)
Maricris R. Sindrijas Magdagooc, Jabonga, Agusan del norte 9344749348 With full and handwritten
name tag and signature over
Brgy. 7 Cabadbaran City, Agusan del printed name
Mae A. Oronan norte 9261831346
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
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable
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 against me. PHOTO

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

ID/License/Passport No.: 2045642

Signature (Sign inside the box)

Date/Place of Issuance: 05/12/2019 PRC BUTUAN

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