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 GULANE
NAME EXTENSION (JR., SR)
FIRST NAME GERALYN
MIDDLE NAME GOLIAS
3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 11/19/1996 ✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH JACOPON, DARAM SAMAR If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female
6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS BLOCK 8 LOT 1
Widowed Separated House/Block/Lot No. Street
PICZONVILLE BUNUANAN
Other/s:
Subdivision/Village Barangay
CATBALOGAN CITY SAMAR
7. HEIGHT (m) 1.70 m
City/Municipality Province
8. WEIGHT (kg) 58 kg ZIP CODE 6700
18. PERMANENT ADDRESS BLOCK 8 LOT 1
9. BLOOD TYPE "A"
House/Block/Lot No. Street
PICZONVILLE BUNUANAN
10. GSIS ID NO. 2005514847
Subdivision/Village Barangay
CATBALOGAN CITY SAMAR
11. PAG-IBIG ID NO. 121229067003
City/Municipality Province
12. PHILHEALTH NO. 130255081919 ZIP CODE 6700
13. SSS NO. NONE 19. TELEPHONE NO. NONE
14. TIN NO. 482052157 20. MOBILE NO. 09301146113
15. AGENCY EMPLOYEE NO. 6302167 21. E-MAIL ADDRESS (if any) geralyn.gulane@deped.gov.ph
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME N/A
MIDDLE NAME
OCCUPATION
EMPLOYER/BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.
24. FATHER'S SURNAME GULANE
NAME EXTENSION (JR., SR)
FIRST NAME ARTURO
MIDDLE NAME APOSTOL
25. MOTHER'S MAIDEN NAME
SURNAME GULANE
FIRST NAME SUSANA
MIDDLE NAME GOLIAS (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
ELEMENTARY CATBALOGAN III ELEMENTARY SCHOOL PRIMARY EDUCATION 2003 2009 2009 NONE
VOCATIONAL
SECONDARY / SAMAR NATIONAL SCHOOL HIGH SCHOOL 2009 2013 2013 NONE
N/A
TRADE
COURSE
COLLEGE SAMAR STATE UNIVERSITY Bachelor of Elementary Education 2013 2017 2017 NONE
Master of Education Major in Educational
GRADUATE STUDIES SAMAR COLLEGE
Management
2019 9 units NONE
(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 77.4 09/24/2017 Tacloban City 1574994 11/19/2023
(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.
SALARY/ JOB/ GOV'T SERVICE
28. INCLUSIVE DATES
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY PAY GRADE (if
(mm/dd/yyyy) MONTHLY applicable)& STATUS OF
(Write in full/Do not (Write in SALARY STEP (Format APPOINTMENT
abbreviate) full/Do not abbreviate) "00-0")/
From To INCREMENT
(Y/ N)
12/03/2021 Present Teacher I Darahuway Dako Elementary School 24161.00 11-2 Permanent Y
4/16/2019 2/12/2021 Teacher I Darahuway Dako Elementary School 23877.00 11-1 Permanent Y
12/03/2018 4/15/2019 Teacher I (ALS Mobile Teacher) Catbalogan II District 20179.00 11-1 Permanent Y
8/13/2018 10/11/2018 Teacher I Cagusipan Elementary School 20179.00 11-1 Substitute Y
(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
(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
District INSET on School Based Management (SBM) Principles 12/16/2020 12/16/2020 8 Managerial DepEd Schools Division of Catbalogan City
Capability Building for School Health Care Program (SDHCP) 11/26/2020 11/26/2020 8 Managerial DepEd Schools Division of Catbalogan City
DRRM Contingency Planning for School DRRM Coordinators 12/10/2019 12/11/2019 16 Managerial DepEd Schools Division of Catbalogan City
Re-Orientation of DRRM Modules for School DRRM Coordinators 12/05/2019 12/07/2019 24 Managerial DepEd Schools Division of Catbalogan City
Capability Building on Emergency Response and Disaster Preparedness for School
09/25/2019 09/27/2019 24 Managerial DepEd Schools Division of Catbalogan City
DRRM Coordinators and ALS Implementers
Division Training for Elementary and Secondary EPP/ TLE Teachers on Different Pedagogies in
Teaching the Four (4) Components (Agriculture, H.E., ICT & IA)
09/4/2019 09/6/2019 24 Managerial DepEd Schools Division of Catbalogan City
Re-Orientation Workshop on DepEd Order No. 10, s. 2016 Policy and Guidelines for
Comprehensive WinS Program
08/20/2019 08/20/2019 8 Managerial DepEd Schools Division of Catbalogan City
(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)
LITERATE IN BASIC COMPUTER SOFTWARE (MS
WORD, MS EXCEL, POWERPOINT)
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 ✘ NO
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
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:
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
RENANTE T. LEGATUB CATBALOGAN CITY 9173046233 3.5 cm. X 4.5 cm
(passport size)
EDMAR C. MONTEJO CATBALOGAN CITY 9760292768 With full and handwritten
name tag and signature over
printed name
JOHN PAUL D. CRISOSTOMO CATBALOGAN CITY 9502455911
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.: 1574994 Signature (Sign inside the box)
Date/Place of Issuance: TACLOBAN, 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
