PDS 2017
PDS 2017
PDS 2017
212
Revised 2017
I. PERSONAL INFORMATION
2. SURNAME BANGLOY
NAME EXTENSION (JR., SR
FIRST NAME CARMELITA
MIDDLE NAME MANALILI
3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 07/14/1983 ✘ Filipino Dual Citizenship
by birth by
BUTUAY, JIMINEZ, MISAMIS
4. PLACE OF BIRTH If holder of dual citizenship, Pls. indicate cou
OCCIDENTAL
please indicate the details.
5. SEX Male ✘ Female
SURNAME SUMAGANG
FIRST NAME LOURDES
MIDDLE NAME RESABA (Continue on separate sheet if necessary
SUMASAP ELEMENTARY
ELEMENTARY 1990 1996
SCHOOL
SCHOOL OF SAINT JOHN THE
SECONDARY /
VOCATIONAL 1996 2000
BAPTIST
SIGNATURE DATE
CS FORM
L DATA SHEET
erience Sheet shall cause the filing of administrative/criminal case/s against the person
Dual Citizenship
by naturalization
P3
Street
VILLA KANANGA
Barangay
AGUSAN DEL NORTE
Province
8600
P3
Street
VILLA KANANGA
Barangay
AGUSAN DEL NORTE
Province
N-O-N-E
09305172809
carmelita.bangloy@deped.gov.ph
7/21/2015
(Continue on separate sheet if necessary)
SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED
1996
2000
2005
SIGNATURE DATE
CS FORM 212 (Revised 20
LICENSE (if applicable)
Date of
Validity
GOV'T
SERVICE
(Y/
N)
YES
YES
arate sheet if necessary)
N-O-N-E
COOKING
DRIVING
VOLLEYBALL
BASEBALL
SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S
CONDUCTED/ SPONSORED BY
(Write in full)
REGION
REGION
DIVISION
DIVISION
DIVISION
DIVISION
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)
eparate sheet if necessary)
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘
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? ________________________________
________________________________
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:
MARILYN L. PASOK BAAN ELEMENTARY SCHOOL 09197806317 With full and handwritten
name tag and signature over
printed name
FROILAN S. OLIT ANTICALA ELEMENTARY SCHOOL 09487981138
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
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.
SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.