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 LIMEN
NAME EXTENSION (JR., SR)
FIRST NAME RICHAELLOU

MIDDLE NAME MAGHARI

3. DATE OF BIRTH
(mm/dd/yyyy) 10/16/1990 16. CITIZENSHIP FILIPINO

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

17. RESIDENTIAL ADDRESS PUROK 5, POBLACION LAAK COMPOSTELA VALLEY

6 CIVIL STATUS SINGLE
House/Block/Lot No. Street

Subdivision/Village Barangay
7. HEIGHT (m) 1.49 LAAK COMPOSTELA VALLEY
City/Municipality Province
8. WEIGHT (kg) 45 ZIP CODE 8100

18. PERMANENT ADDRESS PUROK 5, POBLACION LAAK COMPOSTELA VALLEY

9. BLOOD TYPE O
House/Block/Lot No. Street

10. GSIS ID NO. NONE MAGUGPO WEST

Subdivision/Village Barangay
LAAK COMPOSTELA VALLEY
11. PAG-IBIG ID NO. 915352918788
City/Municipality Province

12. PHILHEALTH NO. 16-000080287-2 ZIP CODE 8810

13. SSS NO. NONE 19. TELEPHONE NO. NONE

14. TIN NO. 478-108-144 20. MOBILE NO. 0912-236-9202

15. AGENCY EMPLOYEE NO. 8405030 21. E-MAIL ADDRESS (if any) [email protected]

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

NAME EXTENSION (JR., SR)

FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME LIMEN

FIRST NAME RICARDO

MIDDLE NAME SOMBILON

25. MOTHER'S MAIDEN NAME

SURNAME MAGHARI

FIRST NAME LUCIA

MIDDLE NAME JUANILLO (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
3RD
ELEMENTARY LAAK CENTRAL ELEMENTARY SCHOOL ELEMENTARY EDUCATION 1997 2002 GRADUATED 2002 HONORABL
E
VOCATIONAL WITH
SECONDARY / LAAK NATIONAL HIGH SCHOOL SECONDARY EDUCATION 2002 2006 GRADUATED 2006 MERIT
2ND
LAAK FOUNDATION INCORPORATED HEALTH CARE SERVICING II 2007 2009 GRADUATED 2009 HONOR
TRADE BACHELOR OF SECONDARY EDUCATION
COLLEGE
COURSE UNIVERSITY OF MINDANAO
MAJOR IN BIOLOGICAL SCIENCE
2010 2014 GRADUATED 2014 NONE

GRADUATE STUDIES NONE

(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 17, 2017 CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT Date of
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT Validity

PROFESSIONAL BOARD EXAM FOR TEACHERS 79.20% 08/17/2014 HOLY CROSS, DAVAO CITY 1346126 05/11/2015

(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. SERVICE
INCLUSIVE DATES SALARY/ JOB/ PAY
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)
DEPARTMENT OF EDUCATION - LAAK SG 11
12/10/2015 PRESENT TEACHER I 19, 620.00
STEP I PERMANENT Y
NATIONAL HIGH SCHOOL

(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 17, 2017 CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (Write in full)
(mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

CATHOLIC MINISTRY OF LECTORS 04/26/2014 PRESENT NOT MEMBER

APPLICABLE

(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
3-DAYS SCIENCE CURRICULUM ENHANCEMENT SEMINAR-WORKSHOP FOR GRADE 3-
09/30/16 2/10/2016 24 DepEd LAAK CENTRAL ELEMENTARY SCHOOL GYM
11 TEACHERS TEACHING SCIENCE
2-DAY SCHOOL-LEVEL LIVE-OUT ORIENTATION ON GAD PHILIPPINES, AND BASIC
08/26/16 08/27/16 16 DepEd LAAK NHS CONFERENCE ROOM
ORIENTATION ON GENDER SENSITIVITY AWARENESS
3-DAYS DIVISION SEMINAR WORKSHOP FOR SECONDARY SCHOOL TEACHERS IN COMVAL HOTEL AND RESTAURANT,
11/12/2015 12 13 2015 24 DepEd
PROCESS SKILLS WITH TABLE OF SPECIFICATIONS,SIM, AND ACTION RESEARCH NABUNTURAN COMPOSTELA VALLEY

ONE DAY SCHOOL LEVEL TRAINING-WORKSHOP ON THE MAKING OF RPMS-IMCRF 10 28 2015 10 28 2015 8 DepEd LAAK NHS CONFERENCE ROOM

2-DAYS SCHOOL-LEVEL TRAINING-WORKSHOP ON TEST CONSTRUCTION, ITEM

10 26 2015 10 27 2015 16 DepEd LAAK NHS CONFERENCE ROOM
ANALYSIS AND UTILIZATION OF TEST RESULTS

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION

31. SPECIAL SKILLS and HOBBIES 32. 33. MEMBERSHIP IN ASSOCIATION
(Write in full)

COMPUTER OPERATIONS NONE NONE

TYPING NONE NONE

HEALTH CARE SERVICING/CAREGIVING NONE NONE

GARDENING/PLANTING NONE NONE

(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 17, 2017 CS FORM 212 (Revised 2017), Page 2 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, YES NO
Bureau or Department where you will be apppointed, If YES, give details:
a. within the third degree? ________________________________
________________________________
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
YES NO
court or tribunal?
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 out (abolition) in the YES NO
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 election YES NO
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)

ID picture taken within

NAME ADDRESS TEL. NO. the last 6 months
3.5 cm. X 4.5 cm
LENG, SUSANA C. TAGUM CITY 0918-3115220 (passport size)

With full and handwritten

SORDILLA, APRIL AIME Z. LAAK, COMPOSTELA VALLEY 0948-3860121 name tag and signature over
printed name

AGATINTO, JOY O. LAAK, COMPOSTELA VALLEY 0912-3744308 Computer generated

or photocopied picture
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete is not acceptable
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 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.: 1346126 Signature (Sign inside the box)
APRIL 17, 2017
Date/Place of Issuance: 12/5/2015 DAVAO CITY 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