CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misinterpretation 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 BACULI

FIRST NAME FREEIAH

MIDDLE NAME BAYANG

3. DATE OF BIRTH
(mm/dd/yyyy) 12/6/2005 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH MALIN-AWA, TABUK CITY, KALINGA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS PUROK 2
Widowed Separated House/Block/Lot No. Street
MALIN-AWA
Other/s:
Subdivision/Village Barangay
TABUK CITY KALINGA
7. HEIGHT (m) 60cm
City/Municipality Province
8. WEIGHT (kg) 58 ZIP CODE

18. PERMANENT ADDRESS PUROK 2

9. BLOOD TYPE O+
House/Block/Lot No. Street
MALIN-AWA
10. GSIS ID NO. N/A
Subdivision/Village Barangay
TABUK CITY KALINGA
11. PAG-IBIG ID NO. N/A
City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 3800

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

14. TIN NO. N/A 20. MOBILE NO. 09755740396

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) yyang5771@gamail.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)
SR N/A
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME BACULI

NAME EXTENSION (JR., SR)
FIRST NAME ADOLF HITLER

MIDDLE NAME ONTIS

25. MOTHER'S MAIDEN NAME

SURNAME BAYANG

FIRST NAME MARY LOU

MIDDLE NAME DINANAS (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
GRADU
HONORS
(Write in full) ATED
full) (if not graduated) RECEIVED
From To

ELEMENTARY MALIN-AWA, ELEMENTARY SCHOOL PRIMARY EDUCATION 2011 2017 GRADUATED 2017 N/A

SECONDARY
VOCATIONAL / ST. WILLIAM'S ACADEMY HIGH SCHOOL 2017 2023 GRADUATED 2023 N/A

N/A N/A N/A N/A N/A N/A N/A

TRADE
COURSE
COLLEGE SAINT LOUIS COLLEGE OF BULANAO BACHELOR OF SECONDARY EDUCATION 2023 2027 GRADUATED 2027 N/A

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 06/20/2027 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
PROFESSIONAL BOARD EXAMINATION FOR
81.6 9/30/2018 BAGUIO CITY 1722954 7/13/2022
TEACHERS

(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 SERVICE
SALARY/ JOB/ PAY
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
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)

N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 06/20/2027 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 N/A N/A N/A N/A

N/A N/A N/A N/A N/A

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
ATTENDANCE
30. Type of LD
TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS CONDUCTED/ SPONSORED BY
NUMBER OF HOURS ( Managerial/ Supervisory/
(Write in full) (mm/dd/yyyy) Technical/etc) (Write in full)
From To

BREAD AND PASTRY 11/20/2022 11/22/2022 27 TRAINING

TESDA

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORG
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)
in full)

COMPUTER LITERATE N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 06/20/2027

NT / PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

N/A

N/A

N/A

(Continue on separate sheet if necessary)

PROGRAMS ATTENDED

st five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

TESDA

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

N/A

(Continue on separate sheet if necessary)

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: KALINGA
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
JOHN PAUL DULLIYAO DAGUPAN, TABUK CITY, KALINGA 9063180239 3.5 cm. X 4.5 cm
(passport size)

SER GEO BAYANG MALIN-AWA, TABUK CITY, KALINGA 9675271283 With full and handwritten
name tag and signature over
printed name
SEAN PUYAO TINGLAYAN, KALINGA 9357815869
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete or photocopied picture
is not acceptable
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 administrative/criminal case/s PHOTO
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/License/Passport No.: 12345

Signature (Sign inside the box)
06/20/2027
Date/Place of Issuance: 01/14/2019 BAGUIO 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