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 ROLDAN

FIRST NAME MICAELA NAME EXTENSION (JR., SR) NA

MIDDLE NAME CABBAB

3. DATE OF BIRTH
08/24/1998 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH BANTUGO, NAGBUKEL, ILOCOS SUR If holder of dual citizenship, Pls. indicate country:

please indicate the details.

5. SEX Male ✘ Female
17. RESIDENTIAL ADDRESS N/A N/A
6 CIVIL STATUS ✘ Single Married
Widowed Separated House/Block/Lot No. Street
NA BANTUGO
Other/s:
Subdivision/Village Barangay
NAGBUKEL ILOCOS SUR
7. HEIGHT (m) 1.68
City/Municipality Province
8. WEIGHT (kg) 65 ZIP CODE 2725

18. PERMANENT ADDRESS NA N/A

9. BLOOD TYPE O
House/Block/Lot No. Street
NA BANTUGO
10. GSIS ID NO. NA
Subdivision/Village Barangay
NAGBUKEL ILOCOS SUR
11. PAG-IBIG ID NO. 1212-5702-8124
City/Municipality Province

12. PHILHEALTH NO. 05-025750293-4 ZIP CODE 2725

13. SSS NO. 01-2944157-9 19. TELEPHONE NO. NA

14. TIN NO. 753-524-755-000 20. MOBILE NO. 09922274687

15. AGENCY EMPLOYEE NO. NA 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME NA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) NA
FIRST NAME NA RYE MALCOLM ROLDAN GOROSPE 12/13/20

MIDDLE NAME NA

OCCUPATION NA

EMPLOYER/BUSINESS NAME NA

BUSINESS ADDRESS NA

TELEPHONE NO. NA

24. FATHER'S SURNAME ROLDAN

NAME EXTENSION (JR., SR) NA
FIRST NAME RICARDO

MIDDLE NAME GALZOTE

25. MOTHER'S MAIDEN NAME

SURNAME CABBAB

FIRST NAME EVANGELINE

MIDDLE NAME TOBIA (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

BANTUGO-MISSION ELEMENTARY FIRST HONORABLE

ELEMENTARY PRIMARY 1/6/2005 1/4/2011 GRADUATED 2011 MENTIONED
SCHOOL
NARVACAN NATIONAL CENTRAL JOURNALISM/
SECONDARY /
VOCATIONAL SECONDARY 1/6/2011 1/3/2015 GRADUATED 2015 LEADERSHIP
HIGHSCHOOL AWARD

NA NA NA NA NA NA NA
TRADE
BACHELOR OF SCIENCE IN TOURISM
COURSE
COLLEGE UNIVERSITY OF NORTHERN PHILIPPINES 4/4/2015 05/26/2019 GRADUATED 2019 CUM LAUDE
MANAGEMENT
MASTER IN BUSINESS
GRADUATE STUDIES UNIVERSITY OF NORTHERN PHILIPPINES 10/9/2022 PRESENT 21 UNITS NA NA
ADMINISTRATION
(Continue on separate sheet if necessary)

SIGNATURE DATE August 03, 2023

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
CIVIL SERVICE ELIGIBILITY , PROFESSIONAL/ FIRST CIVIL SERVICE COMISSION (CSC) - REGIONAL
N/A 05/22/2019 100101190236 05/29/2019
AND SECOND LEVEL OFFICE 1, SAN FERNANDO, LA-UNION

(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/ SERVICE
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY PAY 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)
ILOCOS SUR POLYTECHNIC STATE COLLEGE,
11/9/2023 10/2/2023 INSTRUCTOR I
CANDON CAMPUS
165.71/HR 12-1 PART-TIME YES

ILOCOS SUR POLYTECHNIC STATE COLLEGE,

03/27/2023 07/08/2023 INSTRUCTOR I
CANDON CAMPUS
165.71/HR 12-1 PART-TIME YES

ILOCOS SUR POLYTECHNIC STATE COLLEGE,

09/26/2022 10/2/2023 INSTRUCTOR I
CANDON CAMPUS
156.86/HR 12-1 PART-TIME YES

ILOCOS SUR POLYTECHNIC STATE COLLEGE,

03/11/2022 07/08/2022 INSTRUCTOR I
CANDON CAMPUS
156.86/HR 12-1 PART-TIME YES

03/05/2021 04/03/2022 GIP/VOLUNTEER LOCAL GOVERNMENT UNIT OF NAGBUKEL 7000.00 340/DAY CONTRACTUAL YES

03/02/2020 07/16/2020 FRONT OFFICE ASSOCIATE 88 COURTYARD HOTEL 13000.00 537/DAY CONTRACTUAL NO

08/17/2019 11/29/2019 FRONT DESK CLERK/CASHIER VITALIS VILLAS. 7000.00 340/DAY CONTRACTUAL NO

(Continue on separate sheet if necessary)

SIGNATURE DATE August 03, 2023

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

TI AGTUTUBO AGDAMA KEN MASAKBAYAN TI PAROKIA 04/21/2017 04/23/2017 30.0 MEMBER

NATIONAL SERVICE TRAINING PROGRAM 09/15/2015 03/19/2016 300.0 STUDENT

CADETTE OFFICER LEADERSHIP TRAINING, NNCHS 05/21/2014 03/28/2015 500.0 CADETTE CAPTAIN

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
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

NC3 IN EVENTS MANAGEMENT 11/12/2022 11/12/2022 8 MANAGERIAL TESDA

LOCAL TOURGUIDING SERVICES , (LECTURER) 06/10/2022 06/10/2022 8 SKILL TRAINING ISPSC CANDON CAMPUS

GOVERNMENT INTERSHIP PROGRAM, DOLE 05/21/2020 11/8/2020 1000 SKILL TRAINING DEPARTMENT OF LABOR AND EMPLOYMENT

ENTREPRENEURSHIP SEMINAR 06/30/2020 06/30/2020 5.0 QUALITY DEPARTMENT OF TRADE INDUSTRY

INTERNSHIP PROGRAM IN THAILAND 12/16/2018 9/4/2019 700.0 SKILL TRAINING CENTER FOR STUDENT INTERNSHIP

COLLEGE OF HOSPITALITY AND TOURISM

ON-THE-JOB TRAINING @ UNP, HOSTEL 5/8/2018 11/20/2018 150.0 SKILL TRAINING
MANAGEMANT, UNP
COLLEGE OF HOSPITALITY AND TOURISM
ON-THE-JOB TRAINING @ HOTEL NI AMONG 3/6/2018 3/8/2018 150.0 SKILL TRAINING
MANAGEMANT, UNP
MAGSAYSAY CENTER FOR HOSPITALITY AND
CRUISE AND HOSPITALITY INDUSTRY UPDATES 7/5/2018 7/5/2018 9.0 TECHNICAL
CULINARY ARTS

PUERTO PRINCESA AS AN ECO-TOURRIFIC DESTINATION 3/5/2018 3/5/2018 8.0 MANAGERIAL PUERTO PRINCESA TOURISM OFFICE

STAY AND LEARN PROGRAM PUERTO PRINCESA 04/29/2018 3/5/2018 32.0 SUPERVISORY MICROTEL BY WYNDHAM, PALAWAN

FLIGHT ATTENDANT FOR A DAY 06/24/2017 06/24/2017 11.0 TECHNICAL PTC-MIL COM AVIATION TRAINING CENTER

AMADEUS BASIC COURSE 06/19/2017 06/24/2017 48.0 TECHNICAL AMADEUS, CANADIAN HOSPITALITY

TRENDS AND VIRAL: TODAY'S MILLENIAL OPPORTUNITIES 03/23/2017 03/23/2017 2.0 MANAGERIAL BS-TOURISM CLASS OF 2017

JOB PROVIDER: HOSPITALITY AS AN ENTREPRENEURAL ACTIVITY 03/23/2017 03/23/2017 2.0 MANAGERIAL BS-TOURISM CLASS OF 2017

FUSION:MAKING ASIAN, WESTERN AND EUROPEAN STRATEGY TO TRADITIONAL

03/23/2017 03/23/2017 2.0 MANAGERIAL BS-TOURISM CLASS OF 2017
FILIPINO HOSPITALITY

A SUSTAINABLE PATH TO GLOBAL PRODUCTION AND HUMAN RESTORATION 03/23/2017 03/23/2017 2.0 MANAGERIAL BS-TOURISM CLASS OF 2017

INTRODUCTION TO FOOD SAFETY REGULATIONS 05/27/2016 05/27/2016 8.0 SAFETY DEPARTMENT OF TRADE INDUSTRY

TECHNICAL EDUCATION AND SKILLS

CAKE MAKING 1/5/2016 06/19/2016 120.0 MANAGERIAL
DEVELOPMENT AUTHORITY
TOURISM TRANSITIONS LINKING CULTURES DIFFERENT SKILLS AND TALENTS AND
01/29/2016 01/29/2016 10.0 MANAGERIAL BS-TOURISM CLASS OF 2016
PROFESSION:ONE GOAL

IWC PROGRAM 7/12/2015 9/12/2015 30.0 TECHNICAL BRYCE INSPIRED CAREERS

(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)

COMMUNICATION SKILL BEST IN CHRISTIAN LIVING CLASS 2011 N/A

COMPUTER SKILL LEADERSHIP AWARDEE,NATIONAL SERVICE TRAINING PROGRAM 2016

MULTI-TASKING SKILL SERVICE AWARDEE 2019

BROWSING TO SOCIAL MEDIA LEADERSHIP AWARDEE, Tourism Student Organizaion Officer 2019

READING

(Continue on separate sheet if necessary)

SIGNATURE DATE August 03, 2023

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)? YES ✘ NO
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 court or tribunal? YES ✘ NO
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 ✘ YES NO
out (abolition) in the public or private sector?
If YES, give details: Resignation
________________________________
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 to promote/actively campaign for a national or local candidate? YES ✘ NO
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
b. Are you a person with disability? If YES, please specify:
YES ✘ NO
c. Are you a solo parent? If YES, please specify ID No:
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
4.5 cm. X 3.5 cm
RUBYLENE JANE T. BACTADAN, MBA SAN JUAN, ILOOS SUR 09058440042 (passport size)

MARJORIE RHEA DAFUN, Ph.D STA. CATALINA, ILOCOS SUR 09175006070 Computer generated
or photocopied picture
is not acceptable
MARISSA SIL-AY PASAY CITY, MANILA 09273790815
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: PASSPORT

ID/License/Passport No.: P8917562A

Signature (Sign inside the box)
August 03, 2023
Date/Place of Issuance: 09/27/2018/DFA LA UNION
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