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 (Do not fill up. For CSC use only)
I. PERSONAL INFORMATION
2. SURNAME OMAR
NAME EXTENSION (JR., SR)
FIRST NAME NORHANIAH
MIDDLE NAME ITUM
3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) JANUARY 28, 1996
4. PLACE OF BIRTH GATA, POONA-BAYABAO LDS If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX
17. RESIDENTIAL ADDRESS
6 CIVIL STATUS SINGLE
House/Block/Lot No. Street
GATA
Subdivision/Village Barangay
7. HEIGHT (CM) 4'9'' POONA-BAYABAO LANAO DEL SUR
City/Municipality Province
8. WEIGHT (kg) 40kg ZIP CODE 9705
18. PERMANENT ADDRESS
9. BLOOD TYPE "O"
House/Block/Lot No. Street
10. GSIS ID NO. N/A GATA
Subdivision/Village Barangay
11. PAG-IBIG ID NO. N/A POONA-BAYABAO LANAO DEL SUR
City/Municipality Province
12. PHILHEALTH NO. N/A ZIP CODE 9705
13. SSS NO. N/A 19. TELEPHONE NO. N/A
14. TIN NO. 354-002-766-000 20. MOBILE NO. 0912 268 2121 / 0967 869 5185
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any)
II. FAMILY BACKGROUND
DATE OF BIRTH
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all)
(mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME
MIDDLE NAME
OCCUPATION
EMPLOYER/BUSENINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.
24.FATHER'S SURNAME H. SALEM
NAME EXTENSION (JR., SR)
FIRST NAME OMAR
MIDDLE NAME DIMAIPUNG
25. MOTHER'S MAIDEN NAME
SURNAME ITUM
FIRST NAME TONDOGUN
MIDDLE NAME H. RASUL (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
PERIOD OF SCHOLARSH
26. HIGHEST LEVEL/
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE ATTENDANCE YEAR IP/
UNITS
LEVEL (Write in GRADUAT ACADEMIC
EARNED
(Write in full) full) ED HONORS
From To (if not graduated)
RECEIVED
POONI LOMABAO CENTRAL
ELEMENTARY
ELEMENTARY SCHOOL
ELEMENTARY 2004 2010 N/A 2010 DIPLOMA
RAGAYAN NATIONAL HIGH
SECONDARY
SCHOOL
HIGH SCHOOL 2010 2014 N/A 1014 DIPLOMA
VOCATIONAL /
TRADE COURSE N/A N/A N/A N/A N/A N/A N/A
COLLEGE ADIONG MEMORIAL BACHELOR OF ELEMENTARY
POLYTHECNIC STATE COLLEGE EDUCATION
2016 2019 N/A 2019 DIPLOMA
GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A
(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) LICENSE (if applicable)
DATE OF
UNDER SPECIAL LAWS/ CES/ CSEE RATING
EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY / (If Applicable) NUMBER Date of
CONFERMENT
DRIVER'S LICENSE Validity
N/A N/A N/A N/A 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.
28. INCLUSIVE DATES SALARY/ JOB/ GOV'T SERVICE
DEPARTMENT / AGENCY / OFFICE / PAY GRADE (if
(mm/dd/yyyy) POSITION TITLE
COMPANY MONTHLY applicable)& STATUS OF
(Write in full/Do not SALARY STEP (Format APPOINTMENT
(Write in full/Do not abbreviate) "00-0")/
From To abbreviate) INCREMENT (Y/ N)
N/A N/A N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)
SIGNATURE DATE DECEMBER 26, 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 NUMBER
(Write in full) POSITION / NATURE OF WORK
(mm/dd/yyyy) OF HOURS
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 ATTENDANCE
30. Type of LD
NUMBER OF CONDUCTED/ SPONSORED BY
TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS(Write in full) (mm/dd/yyyy) (Managerial/supervis
HOURS / DAYS (Write in full)
or/tichnical/ect)
From To
N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. NON-ACADEMIC DISTINCTIONS / RECOGNITION (Write in full) 33.
(Write in full)
READING N/A N/A
(Continue on separate sheet if necessary)
SIGNATURE DATE DECEMBER 26, 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,
D 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, If YES, give details:
finished contract or 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 (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
MOHSIN IBRAHIM POONA-BAYABAO LANAO DEL SUR (passport size)
With full and handwritten
name tag and signature over
printed name
Computer generated
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 administrative/criminal case/s against me.
PHOTO
Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's
License, etc.) PLEASE INDICATE ID Number and Date of Issuance
Government Issued ID:POSTAL ID
ID/License/Passport NoPRN M13210028671 Signature (Sign inside the box)
Date/Place of IssuanceMARAWI
DECEMBER 26, 2023
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
