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 GUIMMIN

FIRST NAME MICHELLE

MIDDLE NAME PADAYAO

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 01/23/1995 ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH IFUGAO VILLAGE, DIFFUN, QUIRINO If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS
Widowed Separated House/Block/Lot No. Street
IFUGAO VILLAGE
Other/s:
Subdivision/Village Barangay

7. HEIGHT (m) 1.554 DIFFUN QUIRINO

City/Municipality Province
8. WEIGHT (kg) 50 ZIP CODE 3401

18. PERMANENT ADDRESS

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

10. GSIS ID NO. On Process IFUGAO VILLAGE

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121181613998 DIFFUN QUIRINO

City/Municipality Province

12. PHILHEALTH NO. 0625102692-2 ZIP CODE 3401

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

14. TIN NO. 764080861 20. MOBILE NO. 09511855664

15. AGENCY EMPLOYEE NO. NONE 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME NONE 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME N/A N/A N/A

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME GUIMMIN

NAME EXTENSION (JR., SR)
FIRST NAME MARTIN

MIDDLE NAME DAGULON

25. MOTHER'S MAIDEN NAME

SURNAME PADAYAO

FIRST NAME ELIZABETH

MIDDLE NAME TONGAY (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY IFUGAO VILLAGE INTEGRATED SCHOOL ELEMENTARY 2003 2008 GRADUATED 2008 NONE

SECONDARY /
VOCATIONAL CALAOCAN INTEGRATED SCHOOL SECONDARY 2008 2012 GRADUATED 2012 NONE

NONE N/A N/A N/A N/A N/A N/A

TRADE
BACHELOR IN SECONDARY
COURSE
COLLEGE QUIRINO STATE UNIVERSITY 2012 2016 GRADUATED 2016 NONE
EDUCATION

GRADUATE STUDIES NONE N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE
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 80.80 09-25-2016 TOGUEGARAO CITY 150622 01-23-2022

(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) 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)

3/6/2021 07/29/2021 TEACHER 1 RAFAEL PALMA ELEMENTARY SCHOOL 22,316.00 SUBSTITUTE Y

1/6/2017 6/4/2018 PRIVATE SCHOOL TEACHER SOUTHFORT ACADEMY OF CAVITE INC. 7,000.00 N/A CONTRACTUAL N
 (Continue on separate sheet if necessary)

SIGNATURE DATE
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

NONE 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) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

INTERNATIONAL WEBINAR FOR SCHOOL TEACHERS AND LRADERS 12/18/2020 12/20/2020 15 TECHNICAL EDGAR A. NUEVA

BREAD AND PASTRY PRODUCTION NCII 03/16/2017 03/31/2017 160 TECHNICAL GUILIN A. MAMONDONG

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

COOKING NONE NONE

 (Continue on separate sheet if necessary)

SIGNATURE DATE
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: IFUGAO
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
DORIS C. BORDA DON MARIANO PEREZ, DIFFUN, QUIRINO 9750140324 3.5 cm. X 4.5 cm
(passport size)

RUBEN N. NAPUDO IFUGAO VILLAGE, DIFFUN, QUIRINO 9533283208 With full and handwritten
name tag and signature over
printed name
RODERICK A. TADEJA GULAC, DIFFUN, QUIRINO 9759971626
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.

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.: 150622
ID/License/Passport No.: 150622 Signature (Sign inside the box)

Date/Place of Issuance: 12-20-2016 Date Accomplished Right Thumbmark

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

MIGUEL U. NICOLAS JR. PhD

School Principal I
Person Administering Oath

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