CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misinterpretation 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 DELA CRUZ
NAME EXTENSION (JR., SR)
FIRST NAME MICHELLE NONE

MIDDLE NAME BAJADOR

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 11/18/1990 ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH SURALLAH, SOUTH COTABATO If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS PUROK ROSAS

Widowed Separated House/Block/Lot No. Street
LITTLE BAGUIO
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 1.61 SURALLAH SOUTH COTABATO
City/Municipality Province
8. WEIGHT (kg) 55 ZIP CODE 9506

9. BLOOD TYPE "B" ( + )

18. PERMANENT ADDRESS PUROK ROSAS
House/Block/Lot No. Street

10. GSIS ID NO. N/A LITTLE BAGUIO

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1211-9607-9618 SURALLAH SOUTH COTABATO

City/Municipality Province
12. PHILHEALTH NO. 17-201185329-9 ZIP CODE 9512

13. SSS NO. 0111-9515460-8 19. TELEPHONE NO. N/A

14. TIN NO. 733-525-533-000 20. MOBILE NO. 09366943760

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) michelledelacruz570@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME DELA CRUZ 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME RICKY N/A RICHELLE MAE BAJADOR DELA CRUZ 05/21/2012

MIDDLE NAME ANIVERSARIO

OCCUPATION DRIVER
EMPLOYER/BUSINESS NAME GAME-IL BAKERY PRODUCTS WHOLESALING
BUSINESS ADDRESS SINSUAT ST., KORONADAL CITY, SOUTH COTABATO
TELEPHONE NO. 0917-629-0357
24. FATHER'S SURNAME BAJADOR
NAME EXTENSION (JR., SR)
FIRST NAME EDGARDO N/A

MIDDLE NAME SOLANO

25. MOTHER'S MAIDEN NAME

SURNAME CABAYA
FIRST NAME MERCY
MIDDLE NAME CALIBAYAN (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
From To

ELEMENTARY LITTLE BAGUIO ELEMENTARY SCHOOL PRIMARY EDUCATION 1997 2003 GRADUATED 2003 N/A

VOCATIONAL
SECONDARY / LIBERTAD NATIONAL HIGH SCHOOL HIGH SCHOOL 2003 2007 GRADUATED 2007 N/A

HOLY CHILD COLLEGE OF INFORMATION 2 YEAR DIPLOMA OF INFORMATION

2007 2009 GRADUATED 2009 N/A
TECHNOLOGY, INC. TECHNOLOGY - (LEP)
TRADE RAMON MAGSAYSAY MEMORIAL BACHELOR OF SECONDARY SSS EDUCATIONAL LOAN/
COLLEGE
COURSE 2016 2020 GRADUATED 2020 CHED-TULONG DUNONG
COLLEGES -MARBEL INCORPORATED EDUCATION- MAJOR IN ENGLISH SCHOLARSHIP

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

(Continue on separate sheet if necessary)

SIGNATURE DATE MARCH 07, 2022

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 86.60% 09/26/2021 NDMU-IBED, KORONADAL CITY 1883912 11/18/2025

(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) STATUS OF
(Write in full/Do not (Write in MONTHLY SALARY applicable)& STEP
APPOINTMENT
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)
51 TALK-China Online Education Group
03/24/2022 PRESENT ESL TEACHER 9,000.00 N/A CONTRACTUAL N/A
Company

(Continue on separate sheet if necessary)

SIGNATURE DATE MARCH 07, 2022

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

INTRODUCTION TO TESOL-TEACHING ENGLISH TO SPEAKERS OF OTHER LANGUAGES 03/20/2021 03/22/2021 24 HRS. ASHLEY POTHECARY CEO

CERTIFICATE OF TESOL AND TEYL-TEACHING ENGLISH TO SPEAKERS OF

OTHER LANGUAGES AND TEACHING ENGLISH TO YOUNG LEARNERS 03/23/2021 03/27/2021 140 HRS. ASHLEY POTHECARY CEO

COMPUTER SYSTEMS SERVICING NCII 6/1/2022 02/16/2022 268 HRS ENGR. ROMEO S. SUSTIGUER, SR.

(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)

1. PROFICIENT IN MS APPLICATIONS (MS

N/A N/A
WORD, EXCEL, PPT) BOWSING NET

2. SINGING N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE MARCH, 07,2022

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 ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘

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? ________________________________
________________________________

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 within
JADE T. PALOMAR SURALLAH, SOUTH COTABATO 9473361378 the last 6 months
3.5 cm. X 4.5 cm
(passport size)
GILBERT B. BARRERA SURALLAH, SOUTH COTABATO 9688542379
With full and handwritten
name tag and signature over
printed name
JESSIE EMMANUEL L. GALLEGO KORONADAL, CITY 9195407159
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 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
ID/License/Passport No.: 1883912 Signature (Sign inside the box)
MARCH 07,2022
Date/Place of Issuance: 01-07-2022/ PRC-KORONADAL 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