CS Form No.
212
Revised 2017 Unique Applicant Number
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 POCULAN
FIRST NAME ANGELA NAME EXTENSION (JR., SR) N/A
MIDDLE NAME ATAMOSA
3. DATE OF BIRTH
(mm/dd/yyyy) 1/17/2001 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by
✘ birth by naturalization
4. PLACE OF BIRTH POBLACION, ROSARIO AGUSAN DEL SUR If holder of dual citizenship, Pls. indicate country:
Male ✘ Female please indicate the details.
5. SEX
✘ Single Married 17. RESIDENTIAL ADDRESS N/A P5
6 CIVIL STATUS
Widowed Separate House/Block/Lot No. Street
d N/A POBLACION
Other/s:
Subdivision/Village Barangay
ROSARIO AGUSAN DEL SUR
7. HEIGHT (m) 1.57
City/Municipality Province
8. WEIGHT (kg) 48 ZIP CODE 8504
18. PERMANENT ADDRESS N/A P5
9. BLOOD TYPE O
House/Block/Lot No. Street
N/A POBLACION
10. GSIS ID NO. N/A
Subdivision/Village Barangay
ROSARIO AGUSAN DEL SUR
11. PAG-IBIG ID NO. N/A
City/Municipality Province
12. PHILHEALTH NO. 18-252083866-0 ZIP CODE 8504
13. SSS NO. N/A 19. TELEPHONE NO. N/A
14. TIN NO. N/A 20. MOBILE NO. 0950 183 3088
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDp angelapoculan5@gmail.com
II. FAMILY BACKGROUND
DATE OF BIRTH
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
(mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME N/A 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 POCULAN
NAME EXTENSION (JR., SR) N/A
FIRST NAME AGUSTIN
MIDDLE NAME DELACRUZ
25. MOTHER'S MAIDEN NAME
SURNAME POCULAN
FIRST NAME DELIA
MIDDLE NAME ATAMOSA (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND S
HIGHEST
BASIC LEVEL/ SCHOLARSHIP
26. NAME OF SCHOOL PERIOD OF ATTENDANCE YEAR
EDUCATION/DEGREE/COURSE UNITS / ACADEMIC
LEVEL (Write in GRADU
(Write EARNED HONORS
full) ATED
in full) From To (if not RECEIVED
graduated)
ELEMENTARY ROSARIO CENTRAL ELEMENTARY SCHOOL ELEMENTARY 2007 2012 GRADUATED 2012 DIPLOMA
DATU LIPUS MAKAPANDONG NATIONAL HIGH
SECONDARY HIGH SCHOOL 2013 2019 GRADUATED 2019 DIPLOMA
SCHOOL
AGUSAN DEL SUR STATE COLLEGE OF BACHELOR OF SECONDARY
COLLEGE EDUCATION MAJOR IN ENGLISH
2019 2023 GRADUATED 2023 DIPLOMA
AGRICULTURE & TEACHNOLOGY
GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A
GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)
SIGNATURE DATE January 25, 2019
01/08/2024
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
LICENSED PROFESSIONAL TEACHER 81.20% 09/24/2023 DAVAO CITY N/A N/A
(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
(mm/dd/yyyy) MONTHLY PAY GRADE (if STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To
(Y/ N)
(Continue on separate sheet if necessary)
SIGNATURE DATE 01/08/2024
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (Write in
full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To
N/A 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
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) From To Technical/etc)
(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)
Technology literate N/A
Awareness and appreciation of cultural diversity.
Flexible
Ability to collaborate with colleagues to enhance
the overall educational experience.
(Continue on separate sheet if necessary)
SIGNATURE DATE 01/08/2024
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? 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 YES ✘ NO
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, YES ✘ NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or If YES, give details:
phased 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 YES ✘ NO
(except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
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? 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
a. items:
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
POBLACION, ROSARIO, AGUSAN the last 6 months
STEVEN G. BASAN 9638330253 3.5 cm. X 4.5 cm
DEL SUR (passport size)
POBLACION, ROSARIO, AGUSAN
ARDE A. POCULAN 9382964856 With full and handwritten
DEL SUR name tag and signature over
printed name
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 PHOTO
filing of 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:
ID/License/Passport No.:
Signature (Sign inside the box)
Date/Place of Issuance:
01/08/2024
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
