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 GALOLA
NAME EXTENSION (JR., SR)
FIRST NAME LADYBE N/A
MIDDLE NAME MALIMOT
3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 11/5/1998 ✘

4. PLACE OF BIRTH TAGBILARAN CITY, BOHOL If holder of dual citizenship, Pls. indicate country:
✘ please indicate the details.
5. SEX

6 CIVIL STATUS
✘
17. RESIDENTIAL ADDRESS PUROK 6 N/A
House/Block/Lot No. Street
N/A TAGUIHON
Subdivision/Village Barangay
7. HEIGHT (m) 1.651 m BACLAYON BOHOL
City/Municipality Province
8. WEIGHT (kg) 70 kg ZIP CODE 6301

9. BLOOD TYPE A+
18. PERMANENT ADDRESS PUROK 6 N/A
House/Block/Lot No. Street

10. GSIS ID NO. N/A N/A TAGUIHON

Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A BACLAYON BOHOL

City/Municipality Province

12. PHILHEALTH NO. 120259183419 ZIP CODE 6301

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

14. TIN NO. 345-395-925-000 20. MOBILE NO. 09488658648

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME GALOLA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME CARLO N/A N/A

MIDDLE NAME BUNAOS

OCCUPATION POLICE OFFICER- PATROLMAN

EMPLOYER/BUSINESS NAME PHILIPPINE NATIONAL POLICE

BUSINESS ADDRESS CAMP CRAME, QUEZON CITY, METRO MANILA

TELEPHONE NO. N/A

24. FATHER'S SURNAME MALIMOT

NAME EXTENSION (JR., SR)
FIRST NAME BENECIO N/A
MIDDLE NAME NARIT

25. MOTHER'S MAIDEN NAME

SURNAME SALPUCAL

FIRST NAME ELISA

MIDDLE NAME REQUIERME (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

WITH
ELEMENTARY GUIWANON ELEMENTARY SCHOOL PRIMARY EDUCATION 2005 2011 GRADUATED 2011
HONOR
DR. CECELIO PUTONG NATIONAL HIGH
SECONDARY /
VOCATIONAL HIGH SCHOOL 2011 2015 GRADUATED 2015 N/A
SCHOOL

N/A
TRADE
BACHELOR OF SECONDARY
COURSE
COLLEGE BOHOL ISLAND STATE UNIVERITY 2015 2019 GRADUATED 2019 N/A
EDUCATION MAJOR IN ENGLISH

GRADUATE STUDIES N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE JUNE 16, 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

RA 1080 (LICENSED PROFESSIONAL TEACHER) 77.80 01/30/2022 TAGBILARAN CITY, BOHOL 1902248 11/5/25

(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
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To
(Y/ N)
GOVERNOR CELESTINO GALLARES CONTRACT OF
08/26/2020 PRESENT ADMIN ASSISTAN II 18,251 8 SERVICE
YES
MEMORIAL HOSPITAL

(Continue on separate sheet if necessary)

SIGNATURE DATE JUNE 16, 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

(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
ANNETTE L. SALLILAS, MD, FPSP,
BIORISK MANAGEMENT 08/26/2020 08/26/2020 8 HRS
FASCP, MIAC
ELLAN LYLL B. SALADA, MD, FPCP,
INFECTION PREVENTION AND CONTROL WEBINAR 12/14/2021 12/14/2021 8 HRS FPSMID- IPCU CHAIRMAN
MARIA LUZ JOANNA B. SORIA,
QUALITY MANAGEMENT SYSTEM 4/28/2022 4/28/2022 8 HRS MD, FPCP- ISO CHAIRPERSON

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

COMPUTER LITERATE N/A YOUTH FOR PADAYON BACLAYON

COOKING

LISTENING TO MUSIC

DANCING

(Continue on separate sheet if necessary)

SIGNATURE DATE JUNE 16, 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? ✘

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

If YES, give details:

35. a. Have you ever been found guilty of any administrative offense? ✘

If YES, give details:

________________________________
________________________________
b. Have you been criminally charged before any court? ✘

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 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 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 ✘
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last ✘

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? ✘

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? ✘

If YES, please specify:

b. Are you a person with disability? ✘

If YES, please specify ID No:

c. Are you a solo parent? ✘

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
MARIA ALDA LIGASON BOOL, TAGBILARAN CITY, BOHOL 411-4868 local 293 3.5 cm. X 4.5 cm
(passport size)

GENSE MARIE M. INTING TAGUIHON, BACLAYON, BOHOL 09206385268 With full and handwritten
name tag and signature over
printed name
ATTY. ALVIN J. UY SAN VICENTE, BACLAYON, BOHOL 09462395067
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

ID/License/Passport No.: 1902248 Signature (Sign inside the box)

04/22/22/ TAGBILARAN CITY, 06/16/2022
Date/Place of Issuance:
BOHOL Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this 24th day of May 2021, affiant exhibiting his/her validly issued government ID as indicated above.

Person Administering Oath

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