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 P A R A G A T O S

FIRST NAME MA. ROSELYN

MIDDLE NAME D O N C E R A S
3. DATE OF BIRTH
(mm/dd/yyyy) 11/23/1994 16. CITIZENSHIP

4. PLACE OF BIRTH Catbalogan Samar If holder of dual citizenship, Philippines

please indicate the detail.
5. SEX Female region VIII
17. RESIDENTIAL ADDRESS ANCIENTLY LIVE PUROK'1 EXTENSION ' A
6 CIVIL STATUS Single
House/Block/Lot No. Street
CANLAPWAS HOME BRGY CANLAPWAS
No married
Subdivision/Village Barangay
CATBALOGAN SAMAR
7. HEIGHT (m) 5'4
City/Municipality Province
8. WEIGHT (kg) 58kg ZIP CODE 6700

18. PERMANENT ADDRESS 0111 Navarette st

9. BLOOD TYPE Type A+
House/Block/Lot No. Street
Villa Hermosa village Brgy San Andres stio santo Niño
10. GSIS ID NO. NONE
Subdivision/Village Barangay
CATBALOGAN SAMAR
11. PAG-IBIG ID NO. 1212-7610-5967
City/Municipality Province

12. PHILHEALTH NO. 13-025264045-3 ZIP CODE 6700

13. SSS NO. 34-9829691-5 19. TELEPHONE NO. None

14. TIN NO. 772-345-464 20. MOBILE NO. 09942231019 - 09658990065

15. AGENCY EMPLOYEE NO. NONE 21. E-MAIL ADDRESS (if any) [email protected]

II. FAMILY BACKGROUND

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

NAME EXTENSION (JR., SR) NOT APPLICABLE

FIRST NAME NINETA
RACHEL PARAGATOS KAIKLIAN
MIDDLE NAME ABOGANDA 4/15/1995
REYNALDO PARAGATOS KAIKLIAN
OCCUPATION BRGY ELECTION LEADER / BRGY OFFICER CDO 6/28/1996
LEONARDO PARAGATOS KLAS
EMPLOYER/BUSINESS NAME TAN'S BRGY LEADER ANCIENTLY 4/20/2000

BUSINESS ADDRESS BRGY ELECTION LEADER

TELEPHONE NO. 9458990065

24. FATHER'S SURNAME PARAGATOS

FIRST NAME MARCIANO

MIDDLE NAME CONDE

25. MOTHER'S MAIDEN NAME PARAGATOS

SURNAME KLAS

FIRST NAME RENITA

MIDDLE NAME DONCERAS (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
(Write in full) HONORS
full) (if not graduated) RECEIVED
From To

ELEMENTARY Bliss elementary school 6/10/2006 3/30/2007 2007

SECONDARY /
VOCATIONAL Samar national highschool 6/12/2013 3/31/2014 2014

Tesda NC1 NCII Welding shield metal arc SMAW 9/1/2021 12/29/2021 2021
TRADE
Bachelor of science industrial technology in
COURSE
COLLEGE Samar State University
entrepreneurship
8/12/2022 6/4/2023 2023

Bachelor of science Industrial technology in

GRADUATE STUDIES College of industrial technology
entrepreneurship
8/12/2022 6/4/2023 2023
(Continue on separate sheet if necessary)

SIGNATURE DATE 01, 26, 24

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

(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)

3/10/2022 7/15/2022 JOLLIBEE CATBALOGAN WIZARD TACLOBAN CITY 13000.00

FIVE STAR CORPORATION TACLOBAN

8/10/2022 12/3/2022 MANG INASAL CATBALOGAN CITY ALLOWANCE
CITY
A'PLUS LEYTE CRADET CORPORATION
10/12/2023 1/11/2024 LEYTE A'+ CRADET CORPORATION 12000.00
SSS-GSIS PENSIONERS
12/5/2023 7/3/2023 SAMAR STATE UNIVERSITY CHED ALLOWANCE

(Continue on separate sheet if necessary)

SIGNATURE DATE 01/26/24

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 O N E

(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

N O N E

(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
(Write in full)
full)

Computer literature system servicing

Accountant NONE

Inventory system

Shield metal arc welding TESDA SMAW NCI-NCII

Management
(Continue on separate sheet if necessary)

SIGNATURE DATE 01 ,26, 2024

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
3.5 cm. X 4.5 cm
ELPHA ESTORNINOS DE JESUS - BOARDMEMBER SECOND
BRGY CANLAPWAS 0905-528-9296 (passport size)
DISTRICT OF SAMAR
With full and handwritten
MR. RONIE VELASCO - COLLE OF DEAN SAMAR STATE UNIVERSITY 09499535566 name tag and signature over
printed name
MR. GIL O. AMOYAN,PH.D - DIRECTOR STUDENTS Computer generated
SAMAR STATE UNIVERSITY 09499535566
INTERNSHIP PROGRAM or photocopied picture
is not acceptable
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and
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: Philhealth ID 13-0252640445-5

ID/License/Passport No.: NONE

Signature (Sign inside the box)
01/26/2024
Date/Place of Issuance: 05,20,2023
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