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. (Do not fill up. For CSC use only)
I. PERSONAL INFORMATION
2. SURNAME QUIJANO
FIRST NAME ADELIA NAME EXTENSION (JR., SR) N/A

MIDDLE NAME ABRENICA Wi

3. DATE OF BIRTH
(mm/dd/yyyy) 11/25/1961 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by
by naturalization
4. PLACE OF BIRTH LABAO, BAYUGAN CITY, AGUSAN DEL SUR If holder of dual citizenship, birth country:
Pls. indicate

5. SEX please indicate the details.

Male ✘ Female Ot

6 CIVIL STATUS 17. RESIDENTIAL ADDRES PUROK-9

Single Married
✘ Widowed Separate House/Block/Lot No. Street
d MARCELINA
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 1.50 BAYUGAN CITY AGUSAN DEL SUR
City/Municipality Province
8. WEIGHT (kg) 61 ZIP CODE 8502

9. BLOOD TYPE A 18. PERMANENT ADDRES PUROK-9

House/Block/Lot No. Street
10. GSIS ID NO. 61112502776 MARCELINA
Subdivision/Village Barangay
11. PAG-IBIG ID NO. 183000008365 BAYUGAN CITY AGUSAN DEL SUR
City/Municipality Province
12. PHILHEALTH NO. 190007940487 ZIP CODE 8502

13. SSS NO. 0809677032 19. TELEPHONE NO. None

14. TIN NO. 174509502 20. MOBILE NO. 09194704839

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if anadelia.quijano001@deped.gov.ph

II. FAMILY BACKGROUND Bo

22. SPOUSE'S SURNAME QUIJANO (DECEASED) 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH
(mm/dd/yyyy)
NAME EXTENSION (JR.,
FIRST NAME JEFFREY SR) N/A CATHERINE A. QUIJANO 11/8/1989
MIDDLE NAME NADELA CHARLIEMAGNE A. QUIJANO 07/17/1990
OCCUPATION N/A JEFADEL A. QUIJANO 10/27/1993

EMPLOYER/BUSINESS NAMN/A JERADEL A, QUIJANO 8/1/1996

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME ABRENICA

NAME EXTENSION (JR.,
FIRST NAME FAUSTO SR) N/A

MIDDLE NAME GADOR

25. MOTHER'S MAIDEN NAME
SURNAME MACAHIBAG
FIRST NAME CONRADA
MIDDLE NAME VENTURA (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND HIGHEST
LEVEL/
26. PERIOD OF SCHOLARSHIP
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE ATTENDANCE YEAR
LEVEL UNITS / ACADEMIC
GRADUA HONORS
(Write in full) (Write in full) EARNED
From To TED RECEIVED
(if not
ELEMENTARY SINADYAP ELEMENTARY SCHOOL PRIMARY EDUCATION 1969 1975 GRADUATED
graduated) 1975 3RD HONOR
VOCATIONAL /
SECONDARY GINGOOG CITY HIGH SCHOOL HIGH SCHOOL OLD CURRICULUM 1976 1980 GRADUATED 1980 NONE
N/A N/A N/A N/A N/A N/A N/A

COLLEGE AGUSAN DEL SUR COLLEGE BACHELOR IN SECONDARY GRADUATED 1986 NONE
EDUCATION-ENGLISH 1980 1986
TRADE COURSE
GRADUATE STUDIES BUKIDNON STATE UNIVERSITY MASTER OF ARTS IN EDUCATION 2001 2009 30 UNITS N/A N/A
(Continue on separate sheet if necessary)
SIGNATURE DATE JANUARY 30, 2023 CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) DATE OF LICENSE (if applicable)
UNDER SPECIAL LAWS/ CES/ CSEE RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY / (If Applicable) CONFERMENT NUMBER Date of
DRIVER'S LICENSE Validity
R.A. 7836 N/A N/A N/A 0617299 11/25/2022

PHILIPPINE TEACHERS PROFESSIONALIZATION

ACT OF 1994

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE SALAR
Y/ JOB/
PAY sheet.
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experience
GRADE GOV'T SERVICE
28. INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / (if
(mm/dd/yyyy) COMPANY MONTHLY applicab STATUS OF
(Write in full/Do not abbreviate) (Write in full/Do not SALARY le)& APPOINTMENT
From To abbreviate) STEP
(Format (Y/ N)
01/01/2022 PRESNT SECONDARY SCHOOL TEACHER -III DEPARTMENT OF EDUCATION-MARCELINA 30,747.00 "00-0")/
NATIONAL HIGH SCHOOL 13-4 PERMANENT Y
INCRE
01/01/2021 12/31/2021 SECONDARY SCHOOL TEACHER -III DEPARTMENT OF EDUCATION-MARCELINA 29,225
NATIONAL HIGH SCHOOL
MENT
13-4 PERMANENT Y

04/15/2020 12/31/2020 SECONDARY SCHOOL TEACHER -III DEPARTMENT OF EDUCATION-MARCELINA 29,225 I3-4 PERMANENT Y
NATIONAL HIGH SCHOOL
01/01/2020 04/14/2020 SECONDARY SCHOOL TEACHER -III DEPARTMENT OF EDUCATION-MARCELINA 27,383
NATIONAL HIGH SCHOOL 13-3 PERMANENT y

01/01/2019 12/31/2019 SECONDARY SCHOOL TEACHER -III DEPARTMENT OF EDUCATION-MARCELINA 25,861

NATIONAL HIGH SCHOOL 13-3 PERMANENT y

01/01/2018 12/31/2018 SECONDARY SCHOOL TEACHER -III DEPARTMENT OF EDUCATION-MARCELINA 24799 13-3 PERMANENT y
NATIONAL HIGH SCHOOL
04/15/2017 12/31/2017 SECONDARY SCHOOL TEACHER -III DEPARTMENT OF EDUCATION-MARCELINA 23,780
NATIONAL HIGH SCHOOL 13-3 PERMANENT y

01/01.2017 04/14/2017 SECONDARY SCHOOL TEACHER -III DEPARTMENT OF EDUCATION-MARCELINA 23,517

NATIONAL HIGH SCHOOL 13-2 PERMANENT y

01/01/2016 12/31/2016 SECONDARY SCHOOL TEACHER -III DEPARTMENT OF EDUCATION-MARCELINA 22,564

NATIONAL HIGH SCHOOL 13-2 PERMANENT y

04/15/2014 12/31/2015 SECONDARY SCHOOL TEACHER -III DEPARTMENT OF EDUCATION-MARCELINA 21,650

NATIONAL HIGH SCHOOL 13-2 PERMANENT y

06/01/2012 04/14/2014 SECONDARY SCHOOL TEACHER -III DEPARTMENT OF EDUCATION-MARCELINA 21,436 13-1 PERMANENT y
NATIONAL HIGH SCHOOL
06/01/2011 05/31/2012 SECONDARY SCHOOL TEACHER -III DEPARTMENT OF EDUCATION-MARCELINA 19,658
NATIONAL HIGH SCHOOL 13-1 PERMANENT y

04/15/2011 05/31/2011 SECONDARY SCHOOL TEACHER -III DEPARTMENT OF EDUCATION-MARCELINA 17,880

NATIONAL HIGH SCHOOL 13-1 PERMANENT y

06/24/2010 04/14/2011 SECONDARY SCHOOL TEACHER -1 DEPARTMENT OF EDUCATION-MARCELINA 16,157

NATIONAL HIGH SCHOOL II-3 PERMANENT Y

04/15/2011 05/31/2011 SECONDARY SCHOOL TEACHER -1 DEPARTMENT OF EDUCATION-MARCELINA 14,775

NATIONAL HIGH SCHOOL 11-3 PERMANENT Y

07/17/2008 06/30/2009 SECONDARY SCHOOL TEACHER -1 DEPARTMENT OF EDUCATION-MARCELINA 12,635 11-3 PERMANENT Y
NATIONAL HIGH SCHOOL
07/01/2008 07/16/2008 SECONDARY SCHOOL TEACHER -1 DEPARTMENT OF EDUCATION-MARCELINA 11,486
NATIONAL HIGH SCHOOL 11-2 PERMANENT Y

07/01/2007 06/30/2008 SECONDARY SCHOOL TEACHER -1 DEPARTMENT OF EDUCATION-MARCELINA 11,207

NATIONAL HIGH SCHOOL 11-2 PERMANENT y

06/17/2005 06/30/2007 SECONDARY SCHOOL TEACHER -1 DEPARTMENT OF EDUCATION-MARCELINA 10.188.16 11-2 PERMANENT
NATIONAL HIGH SCHOOL y

06/17/2002 06/16/2005 SECONDARY SCHOOL TEACHER -1 DEPARTMENT OF EDUCATION-MARCELINA 9939.00 11-1 PERMANENT y
NATIONAL HIGH SCHOOL

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 30, 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 OF
(Write in full) HOURS POSITION / NATURE OF WORK
(mm/dd/yyyy)
From To
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
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING
ATTENDANCE NUMBER (Type of LD
Managerial/ CONDUCTED/ SPONSORED BY
PROGRAMS (Write in full) OF Supervisory/ (Write
(mm/dd/yyyy) HOURS Technical/etc) in full)
From To
DIVISIONAL ORIENTATIO OF LAC FACILITATORS FOR PRIMALS PLUS IN TLE DEPARTMENT OF
FORN JUNIOR HIGH SCHOOL 03/16/2022 03/18/2022 24 TECHNICAL EDUCATION- BAYUGAN CITY
DIVISION
DEPARTMENT OF
NEW NORMAL GOOGLE WORKSPACE AND BASIC VIDEO EDITING 12/17/2021 12/21/2021 24 TECHNICAL EDUCATION- MARCELINA
NATIONAL HIGH SCHOOL

DEPARTMENT OF
10/21/2021 10/21/2021 4.0 TECHNICAL EDUCATION- MARCELINA
SYMPOSIUM ONPSCHOLOGICAL ACTIVITY NATIONAL HIGH SCHOOL
DEPARTMENT OF
10/14/2021 10/14/2021 4.0 TECHNICAL EDUCATION- MARCELINA
MENTAL HEALTH SYMPOSIUM
NATIONAL HIGH SCHOOL
DEPARTMENT OF
03/ 19/2021 03/ 19/ 2021 8.0 TECHNICAL EDUCATION- MARCELINA
HUMAN IMMUNODEFICIENCY VIRUS (HIV) AWARENESS NATIONAL HIGH SCHOOL
DEPARTMENT OF
03/ 26/ 2021 03/ 26/ 2021 8.0 TECHNICAL EDUCATION- MARCELINA
SEMINAR-WORKSHOP ON PSYCOLOGICAL FIRST AID NATIONAL HIGH SCHOOL
DEPARTMENT OF
02/8/ 2021 02/ 10/ 2021 24.0 TECHNICAL EDUCATION- MARCELINA
IN THE CONDUCT OF SCHOOL LEARNING ACTION CELL OF TEACHERS NATIONAL HIGH SCHOOL
DEPARTMENT OF
12/16/ 2020 12/18/ 2020 24.0 TECHNICAL EDUCATION- MARCELINA
THREE-DAYS ICT SEMINAR WORKSHOP NATIONAL HIGH SCHOOL
DEPARTMENT OF
THREE -DAY SEMINAR WORKSHOP ON CRITICAL CONTENT IN ARALING PANLIPUNAN 01/ 15 /2020 01/ 17/2020 24.0 TECHNICAL EDUCATION- BAYUGAN CITY
DIVISION

CASH MANAGEMENT AND CONTROL SYSTEM 09/16/2019 09/18/2019 24.0 TECHNICAL COMMISSION ON AUDIT-REGION

DEPARTMENT OF
THREE DAYS ICT SEMINAR WOKSHOP ( Integration of all subject areas) 12/18/2018 11/20/2018 24.0 TECHNICAL EDUCATION- BAYUGAN CITY
DIVISION

SEMINAR ON BUSINESS PLANNING 11/21/2018 11/23/2018 24.0 TECHNICAL DEPARTMENT OF TRADE &
INDUSTRY

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
31. SPECIAL SKILLS and HOBBIES 32. NON-ACADEMIC DISTINCTIONS / RECOGNITION (Write in full)
33 ASSOCIATION/ORGANIZATION
.
(Write in full)
WATCHING MOVIES N/A N/A

READING MAGAZINE

COOKING

NC 11-HOUSEKEEPING

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2017), Page 3

SIGNATURE DATE JANUARY 30, 2023 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
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:
________________________________
________________________________

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 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
3.5 cm. X 4.5 cm
EFREN B. MARTEL BAYUGAN CITY 9094144941 (passport size)

With full and handwritten

FERNANDO M. CALO BAYUGAN CITY 9198886897 name tag and signature over
printed name

CRISANTO P. BABAO MARCELINA, BAYUGAN CITY 9185136317 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: PRC ID

ID/License/Passport No.: 0617299 Signature (Sign inside the box)

JANUARY 30, 2023

Date/Place of Issuance: NOVEMBER 25,2019 -PRC-BUTUAN
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.

CS FORM 212 (Revised 2017), Page 4 of 4