CS Form No.

212

PERSONAL DATA SHEET

Revised 2017

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 BUSA
NAME EXTENSION (JR., SR)
FIRST NAME GLAIZA

MIDDLE NAME BALANON

3. DATE OF BIRTH
(mm/dd/yyyy)
7/24/1990 16. CITIZENSHIP Filipino Dual Citizenship
by birth by naturalization

4. PLACE OF BIRTH CATBALOGAN CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female

6 CIVIL STATUS Single Married 17. RESIDENTIAL ADDRESS PHASE 1 BLDG 3 MAPAGKUMBABA
Widowed Separated House/Block/Lot No. Street

Other/s:
SIKATUNA BLISS BOTOCAN
Subdivision/Village Barangay
7. HEIGHT (m) 5'2 QUEZON CITY METRO MANILA
City/Municipality Province
8. WEIGHT (kg) 71 KG ZIP CODE 1101

9. BLOOD TYPE O+ 18. PERMANENT ADDRESS SITIO CAABIHAWAN

House/Block/Lot No. Street

10. GSIS ID NO. N/A N/A CABAGO-AN

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121129370564 DOLORES EASTERN SAMAR

City/Municipality Province

12. PHILHEALTH NO. 13-201800602-6 ZIP CODE 6817

13. SSS NO. 34-47909525 19. TELEPHONE NO. N/A

14. TIN NO. 618-162-878-0000 20. MOBILE NO. 09632654413

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) busaglai24@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)
FIRST NAME N/A NICOLE GLENN B. RECENTES 12/29/2012

MIDDLE NAME N/A GWENN NIJHELLE B. RECENTES 6/13/2018

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME BUSA 1/27/1964

FIRST NAME MOISES

MIDDLE NAME BALDAGO

25. MOTHER'S MAIDEN NAME MELBA CHICANO BALANON 5/15/1957

SURNAME BUSA

FIRST NAME MELBA

MIDDLE NAME BALANON (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

SCHOLARSHIP/
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE HIGHEST LEVEL/
YEAR ACADEMIC
LEVEL UNITS EARNED
(Write in full) (Write in full) (if not graduated)
GRADUATED HONORS
RECEIVED
From To
DOLORES CENTRAL ELEMENTARY
ELEMENTARY PRIMARY EDUCATION 06/05/1996 3/30/2002 GRADUATED 2002 WITH HONOR
SCHOOL

SECONDARY DOLORES NATIONAL HIGH SCHOOL HIGH SCHOOL 06/04/2002 03/31/2006 GRADUATED 2006 WITH HONOR

VOCATIONAL /
N/A N/A N/A N/A N/A N/A N/A
TRADE COURSE

EASTERN SAMAR STATE UNIVERSITY BACHELOR OF ELEMENTARY

COLLEGE 06/01/2013 06/07/2019 GRADUATED 2019 N/A
(ESSU CAN-AVID) EDUCATION

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

(Continue on separate sheet if necessary)

SIGNATURE DATE OCTOBBER 9,2023

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 Date of
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT Validity

LICENSURE EXAMINATION FOR TEACHERS 80.40% 09/29/2019 TACLOBAN CITY 1814810 7/24/2025

(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/ PAY
GRADE (if GOV'T
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY STATUS OF
applicable)& STEP SERVICE
(Write in full/Do not abbreviate) (Write in full/Do not abbreviate) SALARY (Format "00-0")/ APPOINTMENT
(Y/ N)
From To INCREMENT

11/14/2022 3/10/2023 SUBSTITUTE TEACHER STELLA MARIS COLLEGE Php. 21,000 N/A SUBSTITUTE N

1/1/2022 3/31/2022 MUNICIPAL PAID TEACHER CABAGO-AN ELEMENTARY SCHOOL Php. 4,000.00 N/A CONTRACTUAL Y

10/1/2021 12/31/2021 MUNICIPAL PAID TEACHER CABAGO-AN ELEMENTARY SCHOOL Php. 4,000.00 N/A CONTRACTUAL Y

4/1/2021 7/31/2021 BARANGAY PAID TEACHER CABAGO-AN ELEMENTARY SCHOOL Php. 1,500.00 N/A CONTRACTUAL Y

1/1/2021 3/31/2021 PROVINCIAL PAID TEACHER DOLORES CENTRAL ELEMENTARY SCHOOL Php. 3,600.00 N/A CONTRACTUAL Y

10/1/2020 12/31/2020 PROVINCIAL PAID TEACHER CABAGO-AN ELEMENTARY SCHOOL Php. 3,600.00 N/A CONTRACTUAL Y

1/1/2020 3/31/2020 MUNICIPAL PAID TEACHER CABAGO-AN ELEMENTARY SCHOOL Php. 1,000.00 N/A CONTRACTUAL Y

10/1/2019 12/31/2019 MUNICIPAL PAID TEACHER CABAGO-AN ELEMENTARY SCHOOL Php. 1,000.00 N/A CONTRACTUAL Y

7/1/2019 9/30/2019 MUNICIPAL PAID TEACHER CABAGO-AN ELEMENTARY SCHOOL Php. 1,000.00 N/A CONTRACTUAL Y

(Continue on separate sheet if necessary)

SIGNATURE DATE OCTOBER 9,2023

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 Type of LD

30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To
COMPUTER LITERACY TRAINING PLUS (MS WORD, MS EXCEL, MS POWERPOINT WITH
4/20/2020 6/5/2020 160 HRS TECHNICAL MATER DIVINAE GRATIAE COLLEGE
ANIMATION, INTERNET AND ALTERNATIVE TOOLS)

4TH INTERNATIONAL MARATHON LECTURE ON EDUCATION 7/25/2022 7/27/2022 36 HRS DepEd NCR

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

COMPUTER LITERATE N/A N/A

COMMUNICATION SKILLS N/A N/A

MULTITASKING N/A N/A

POSITIVE ATTITUDE N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE OCTOBER 9,2023

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,
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 YES NO
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, YES NO
dropped from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in If YES, give details:
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:
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
MANUEL A. QUITORIO DOLORES E. SAMAR N/A 3.5 cm. X 4.5 cm
(passport size)

MARIO C. LASCANO DOLORES E. SAMAR N/A With full and handwritten

name tag and signature over
printed name
PRECY CAMACHO DOLORES E. SAMAR N/A
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 filing of PHOTO
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: PRC ID

ID No.: 1814810
Signature (Sign inside the box)
OCTOBER 9,2023
Date/Place of Issuance: TACLOBAN 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