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 AGUAM
NAME EXTENSION (JR., SR) N/A
FIRST NAME NORAYA
MIDDLE NAME AMEROL
3. DATE OF BIRTH
(mm/dd/yyyy) 11/22/2000 16. CITIZENSHIP
4. PLACE OF BIRTH GANASSI LANAO DEL SUR If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Female
17. RESIDENTIAL ADDRESS N/A N/A
6 CIVIL STATUS Single
House/Block/Lot No. Street
N/A PAGALONGAN
Subdivision/Village Barangay
7. HEIGHT (m) 1.651m GANASSI LANAO DEL SUR
City/Municipality Province
8. WEIGHT (kg) 60 kg ZIP CODE 9311
18. PERMANENT ADDRESS N/A N/A
9. BLOOD TYPE O
House/Block/Lot No. Street
N/A PAGALONGAN
10. GSIS ID NO. N/A
Subdivision/Village Barangay
GANASSI LANAO DEL SUR
11. PAG-IBIG ID NO. N/A
City/Municipality Province
12. PHILHEALTH NO. N/A ZIP CODE 9311
13. SSS NO. N/A 19. TELEPHONE NO. N/A
14. TIN NO. N/A 20. MOBILE NO. 0912-088-0394
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) aguamnoraya416@gmail.com
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) N/A
FIRST NAME 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 AGUAM
NAME EXTENSION (JR., SR) N/A
FIRST NAME NASRODEN
MIDDLE NAME AMEROL
25. MOTHER'S MAIDEN NAME PUMBAE MAROHOM AMEROL
SURNAME AGUAM
FIRST NAME PUMBAE
MIDDLE NAME AMEROL (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
HIGHEST LEVEL/ SCHOLARSHIP/
26. NAME OF SCHOOL PERIOD OF ATTENDANCE YEAR
LEVEL (Write in BASIC EDUCATION/DEGREE/COURSE
(Write in full)
UNITS
GRADUATED
ACADEMIC
HONORS
full) EARNED
(if not graduated) RECEIVED
From To
ELEMENTARY PAMBAGUI ELEMENTARY SHOOL ELEMENTARY 2008 2012 GRADUATED 2012 DIPLOMA
SECONDARY PUALAS NATIONAL HIGH SCHOOL HIGH SCHOOL 2012 2016 GRADUATED 2016 DIPLOMA
VOCATIONAL /
N/A N/A N/A N/A N/A N/A N/A
TRADE
COURSE
COLLEGE PHILIPPINE MUSLIM TEACHER'S COLLEGE BACHELOR OF ELEMENTARY EDUCATION 2021 2023 GRADUATED 2023 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 November 05, 2024
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER RATING DATE OF
SPECIAL LAWS/ CES/ CSEE (If Applicable) EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT NUMBER Date of
Validity
LICENSURE EXAMINATION FOR TEACHER 76.20% 3/17/2024 CAGAYAN DE ORO 2263460 11/22/2028
(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/ PAY SERVICE
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY GRADE (if STATUS OF
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To (Y/ N)
09/08/2024 01/26/2025 VOLUNTEER DEPARTMENT OF EDUCATION 5000 N/A Y
DEPARTMENT OF SOCIAL WELFARE AND
07/07/2024 07/31/2024 ENUMERATOR 24,696 N/A CONTRACTUAL Y
DEVELOPMENT
DEPARTMENT OF SOCIAL WELFARE AND
1/14/2024 2/8/2024 ENUMERATOR
DEVELOPMENT 11,000 N/A CONTRACTUAL Y
7/2/2023 12/23/2024 VOLUNTEER DEPARTMENT OF EDUCATION 5000.00 N/A Y
(Continue on separate sheet if necessary)
SIGNATURE DATE November 05, 2024
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
(Continue on separate sheet if necessary)
VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
INCLUSIVE DATES OF
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE Type of LD
NUMBER OF HOURS
( Managerial/ CONDUCTED/ SPONSORED BY
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To
INTERNSHIP 02/17/2023 03/20/2023 10hrs PHILIPPINE MUSLIM TEACHER'S COLLEGE
(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)
TECHNICAL WRITING N/A PMTC ALUMNI ASSOCIATION
PHOTOGRAPHY N/A N/A
COMPUTER LITERATE N/A N/A
(Continue on separate sheet if necessary)
SIGNATURE DATE November 05, 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?
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, 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
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
4.5 cm. X 3.5 cm
LINANG M. PANGKAT, RSW, MPA MSSD-LSB-MALABNG, LDS 936-9161-852 (passport size)
NORSALIMAH P. SAIPODIN ,RSW MSSD-LSB-GANASSI, LDS 946-5927-914 Computer generated
or photocopied picture
is not acceptable
YAKSAN A. PAGAYAWAN MSSD-LSB-MALABANG, LDS 916-4669-566
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: BARANGAY ID
ID/License/Passport No.: 2023-002 Signature (Sign inside the box)
11/05/2024
Date/Place of Issuance: AUGUST 28, 2023/GANASSI, LDS
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
