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 ag
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

I. PERSONAL INFORMATION
2. SURNAME MISAJON
NAME EXTENSION (JR., SR
FIRST NAME JANE
MIDDLE NAME SUMIDO
3. DATE OF BIRTH
(mm/dd/yyyy) 5/21/1963 16. CITIZENSHIP Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH PAGADIAN CITY, ZAMBOANGA DEL SUR If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male Female

Single Married 17. RESIDENTIAL ADDRESS

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. S
P
Other/s:
Subdivision/Village Ba
STO. NIO SOUTH
7. HEIGHT (m) 5'3
City/Municipality Pr
8. WEIGHT (kg) 66 ZIP CODE 9509
18. PERMANENT ADDRESS
9. BLOOD TYPE B
House/Block/Lot No. S
P
10. GSIS ID NO. 006-0122-0227-2
Subdivision/Village Ba
STO. NIO
11. PAG-IBIG ID NO. 1101-020287-01
City/Municipality Pr

12. PHILHEALTH NO. 12-000002146-1 ZIP CODE 9509

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

14. TIN NO. 155-425-774 20. MOBILE NO. 09261694364

15. AGENCY EMPLOYEE NO. 545-0080 21. E-MAIL ADDRESS (if any)

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME MISAJON 23. NAME of CHILDREN (Write full name and list all)

FIRST NAME SAMIE NAME EXTENSION FARNCES JAY S. MISAJON

(JR., SR)
MIDDLE NAME BODEGAS JESSA MAE S. MISAJON

OCCUPATION SELF - EMPLOYED AIZA JANE S. MISAJON

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME SUMIDO
NAME EXTENSION (JR., SR) SR.
FIRST NAME JULIO
MIDDLE NAME PILAS- PILAS
25. MOTHER'S MAIDEN NAME

SURNAME RICABAR
FIRST NAME LAURA
MIDDLE NAME HERRERA (Continue on separate sheet if necessar

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY PANAY ELEMENTARY SCHOOL ELEMTARY 6/1/1971 ###

SECONDARY PANAY BARANGAY HIGH SCHOOL SECONDARY 6/1/1976 ###

VOCATIONAL /

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

TRADE
COURSE
COLLEGE NOTRE DAME OF MARBEL COLLEGE BACHELOR OF ARTS (A.B.) 6/1/1980 ###

GRADUATE STUDIES NOTRE DAME OF TACURONG COLLEGE MASTER OF ARTS AND EDUCATION 6/1/1994 3/30/1995

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM
L DATA SHEET
erience Sheet shall cause the filing of administrative/criminal case/s against the person

EFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Dual Citizenship

by naturalization

Pls. indicate country:

Street
PANAY
Barangay
SOUTH COTABATO
Province
9509

Street
PANAY
Barangay
SOUTH COTABATO
Province

09261694364

DATE OF BIRTH (mm/dd/yyyy)

3/2/1993
5/24/1995

1/25/2009

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

WITH
1976
HONORS
VALEDICTORI
1980 AN
 N/A N/A

1984 NONE

CAR NONE
parate sheet if necessary)

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

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

(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.
28. INCLUSIVE DATES SALARY/ JOB/ PAY
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY
(Write in full/Do not (Write in SALARY
applicable)& STEP
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To

DEPARTMENT OF EDUCATION- PANAY

1/1/1994 12/31/1994 SECONDARY SCHOOL TEACHER I 3,964.00 SG 10-2
NATIONAL HIGH SCHOOL
DEPARTMENT OF EDUCATION- PANAY
7/7/1992 12/31/1993 SECONDARY SCHOOL TEACHER I 3,133.00 SG 10-1
NATIONAL HIGH SCHOOL
DEPARTMENT OF EDUCATION- PANAY
3/30/1993 9/30/1993 SECONDARY SCHOOL TEACHER I 3,133.00 SG 10-1
NATIONAL HIGH SCHOOL
DEPARTMENT OF EDUCATION- PANAY
1/29/1993 3/29/1993 SECONDARY SCHOOL TEACHER I 3,133.00 SG 10-1
NATIONAL HIGH SCHOOL
DEPARTMENT OF EDUCATION- PANAY
7/7/1989 11/28/1993 SECONDARY SCHOOL TEACHER I 3,133.00 SG 10-1
NATIONAL HIGH SCHOOL
DEPARTMENT OF EDUCATION- PANAY
7/1/1989 9/30/1990 SECONDARY SCHOOL TEACHER I 3,102.00 SG 10-1
NATIONAL HIGH SCHOOL
DEPARTMENT OF EDUCATION- PANAY
1/1/1988 6/30/1988 SECONDARY SCHOOL TEACHER I 1,764.00 SG 10-1
NATIONAL HIGH SCHOOL
DEPARTMENT OF EDUCATION- PANAY
7/1/1987 12/31/1987 SECONDARY SCHOOL TEACHER I 1,604.00 SG 10-1
NATIONAL HIGH SCHOOL
7/1/1987 SECONDARY SCHOOL TEACHER I PANAY BARANGAY HIGH SCHOOL 1,337.00 SG 10-1

1/1/1987 6/31/1987 SECONDARY SCHOOL TEACHER I PANAY BARANGAY HIGH SCHOOL 1,053.00 SG 10-1

7/7/1986 12/31/1986 SECONDARY SCHOOL TEACHER I PANAY BARANGAY HIGH SCHOOL 870.00 SG 10-1
MUNICIPAL PLANNING AND
10/1/1984 7/6/1986 ASSISTANT STATISTICIAN 720.00
DEVELOPMENT OFFICE (LGU-NORALA)
 (Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (R
 LICENSE (if applicable)

NUMBER Date of
Validity

e on separate sheet if necessary)

of duties should be indicated in the attached Work Experience sheet. GOV'T

SERVICE

STATUS OF
APPOINTMENT

(Y/
N)
PERMANENT Y

PERMANENT Y

PERMANENT Y

PERMANENT Y

PERMANENT Y

PERMANENT Y

PERMANENT Y

PERMANENT Y

PERMANENT Y

PERMANENT Y

PERMANENT Y

PERMANENT Y
e on separate sheet if necessary)

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 / NA
From To

KARANCHO, INC. - STO. NIO, SOUTH COTABATO 10/24/1986 PRESENT 24 HRS. SECRETARY/ EMER

(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/ SP
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To

DIVISION SCHOOL PEACE CONGRESS (SOP) 04/18/17 04/18/17 8.0 DEPARTMENT

SOCSARGEN ATHLETIC ASSOCIATION MEET (TEACHNICAL OFFICIAL) 02/18/17 02/22/17 40.0 DEPARTMENT

SOCSARGEN REFRESHER COURSE FOR TECHNICAL OFFICIALS 02/16/17 02/17/17 16.0 DEPARTMENT

NORALA- STO. NIO DISTRICT CLUSTER (MANCOM) 02/08/17 02/08/17 8.0 DEPARTMENT

SOCSARGEN REFRESHER COURSE AND ATHLETIC ASSOCIATION MEET

12/12/16 12/16/16 40.0 DEPARTMENT
( INDIVIDUAL EVENT)

SEMINAR WORKSHOP ON PREPARATION OF TABLE OF SPECIFICATION (TOS)

AND FORMULATION OF HIGHER ORDER THINKING SKILLS QUESTIONS FOR 12/02/16 12/03/16 16.0 DEPARTMENT
SECONDARY SCHOOLS TEACHER TEACHING ARALING PANLIPUNAN

ORIENTATION ON DEPARTMENT OF EDUCATION NEW OBSERVATION TOOL 11/16/16 11/16/16 8.0

DEPARTMEN
REGIONAL TRAINING FOR GRADE 10 TEACHERS IN THE K-12 BASIC EDUCATION
05/11/15 05/16/15 48.0 DEPARTMENT
PROGRAM ( VALUES EDUCATION)
REGIONAL TRAINING OF GRADE 10 TEACHERS IN THE K-12 EDUCATION
04/27/15 05/02/15 48.0 DEPARTMENT
PROGRAM (ARALING PANLIPUNAN)

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHI
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

PLAYING BALLGAMES SILVER MEDAL- SEPAK TAKRAW COACH KABABAYAN

 ASSOCIATION
3RD REGIONAL ATHLETIC ASSOCIATION MEET HARMONY AN
(KARABCHO,
1ST RUNNER UP BEST STRUCTURED CLASSROOM (STO. NIO DISTRICT
SCHOOL YEAR 2016-2017)

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FOR
NT / PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

SECRETARY/ EMERGENCY ASSISTANCE

eparate sheet if necessary)

PROGRAMS ATTENDED
last five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION REGION XII

DEPARTMENT OF EDUCATION REGION XII

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION REGION XII

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION REGION XII

DEPARTMENT OF EDUCATION REGION XII

eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION

(Write in full)

KABABAYAN RIDERS
 ASSOCIATION FOR A NEW CULTURAL
HARMONY AND ORDER, INC.
(KARABCHO, INC.)

eparate sheet if necessary)

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
YES NO
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? RESIGN
________________________________
________________________________
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 with
the last 6 months
MAYLENE S. ORTIGAS PANAY , STO. NIO, SOUTH COTABATO 9173129605 3.5 cm. X 4.5 cm
(passport size)

RAFFY G. HERRERA PANAY , STO. NIO, SOUTH COTABATO 9076347108 With full and handwr
name tag and signatur
printed name
DANILO F. MANVA PANAY , STO. NIO, SOUTH COTABATO 235-1251
Computer generate
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied pictu
is not acceptable
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
ID/License/Passport No.: 0431217 Signature (Sign inside the box)

Date/Place of Issuance: 6-22-2016- DAVAO CITY

Date Accomplished Right Thumbmark

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

Person Administering Oath

CS FORM 212 (Revised
 If YES, give details:
________________________________

If YES, give details:

________________________________
________________________________

If YES, give details:

________________________________
________________________________

If YES, give details:

________________________________
________________________________

If YES, give details:

________________________________
________________________________

NO

If YES, give details (country):

NO

NO

NO

ID picture taken within

the last 6 months
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten

name tag and signature over
printed name

Computer generated
or photocopied picture
is not acceptable

PHOTO

Right Thumbmark

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

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