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

MIDDLE NAME GOTANGO

3. DATE OF BIRTH
05/21/1999 16. CITIZENSHIP Dual
(mm/dd/yyyy) ✘ Filipino
Citizenship
by by
birth naturalization
4. PLACE OF BIRTH NUNGNUNGAN 1, CAUAYAN CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘
Female
6 CIVIL STATUS ✘ Single 17. RESIDENTIAL ADDRESS
Married House/Block/Lot No. Street
Widowe Separa
PUROK 3 NUNGNUNGAN 1
d ted
Other/s: Subdivision/Village Barangay

7. HEIGHT (m) 1.57 CAUAYAN CITY ISABELA

City/Municipality Province
8. WEIGHT (kg) 47 ZIP CODE 3305

18. PERMANENT ADDRESS

9. BLOOD TYPE N/A
House/Block/Lot No. Street

10. GSIS ID NO. N/A PUROK 3 NUNGNUNGAN 1

Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A CAUAYAN CITY ISABELA

City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 3305

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

14. TIN NO. 603-806-559 20. MOBILE NO. 09755184404/09761966186

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) marielletomas4@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

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME TOMAS

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

MIDDLE NAME VALLETE

25. MOTHER'S MAIDEN NAME

SURNAME GOTANGO

FIRST NAME ARCELIE

MIDDLE NAME DAGURO (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 CAUAYAN SOUTH CENTRAL SCHOOL ELEMENTARY EDUCATION 2005 2011 2011 2nd Honors

SECONDARY SAINT XAVIER MONTESSORI SCHOOL SECONDARY EDUCATION 2011 2015 2015 2nd Honorable mention
VOCATIONAL /

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

TRADE
COURSE ISABELA STATE UNIVERISTY- CAUAYAN CITY BACHELOR OF SECONDARY EDUCATION (Major in
COLLEGE CAMPUS Filipino) 2015 2019 2019 N/A

GRADUATE STUDIES Our Lady of the Pillar College- Cauayan City Master of Arts in Education- Filipino 2022 Present 27
(Continue on separate sheet if necessary)

SIGNATURE DATE February 27, 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
BOARD LICENSURE EXAMINATION FOR 85.4 09/29/2019 TUGUEGARAO CITY, CAGAYAN 1825233 05/21/2025
PROFESSIONAL TEACHERS (BLEPT)

(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)

11/28/2023 11/3/2024 TEACHER CAUAYAN CITY NATIONAL HIGH SCHOOL- 27,000 11 SUBSTITUTE Y
MAIN
08/29/2023 11/24/2023 TEACHER CAUAYAN CITY NATIONAL HIGH SCHOOL- 8000/per cut
N/A JOB ORDER N
MAIN off

12/4/2023 07/25/2023 TEACHER CAUAYAN CITY NATIONAL HIGH SCHOOL- 27,000 11 SUBSTITUTE Y
MAIN
11/28/2022 12/3/2023 TEACHER VILLA CONCEPCION NATIONAL HIGH 25,439 11 SUBSTITUTE Y
SCHOOL- MAIN
08/22/2022 10/30/2022 TEACHER VILLA CONCEPCION NATIONAL HIGH 25,439 11 SUBSTITUTE Y
SCHOOL- MAIN
CAUAYAN CITY NATIONAL HIGH SCHOOL- RESEARCH
7/12/2021 4/2/2022 TEACHER ANNEX 23,877 11 SUBSTITUTE Y
CAUAYAN CITY NATIONAL HIGH SCHOOL- RESEARCH
4/10/2021 6/12/2021 TEACHER ANNEX 23,877 11 SUBSTITUTE Y

08/13/2020 07/22/2021 TEACHER PINOMA NATIONAL HIGH SCHOOL 700 N/A VOLUNTEER N

(Continue on separate sheet if necessary)

SIGNATURE DATE February 27, 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
(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 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

2024 DIVISION AND SCHOOL-BASED IN SERVICE TRAINING (INSET) FOR TEACHERS 01/24/2024 01/30/2024 40 TECHNICAL SCHOOLS DIVISION OF CAUAYAN

ONLINE TALAKAYAN: DIGITAL NA PAGBULATLAT SA MGA OBRA MAESTRANG FILIPINO 3/3/2023 3/3/2023 2.0 TECHNICAL ISABELA STATE UNIVERSITY- CAUAYAN CAMPUS

2023 DIVISION AND SCHOOL-BASED IN SERVICE TRAINING (INSET) FOR TEACHERS 6/2/2023 10/2/2023 40 TECHNICAL SCHOOLS DIVISION OF CAUAYAN
National Webinar on Understanding the 2022 DepEd Expanded Career Progression System, IPCRF Plus
Factor, RPMS, and the Frequesntly asked Questions on Publications and Authorship 12/21/2022 12/21/2022 4 TECHNICAL ALOYSIAN PUBLICATIONS

INTEGRATION INSTRUCTION AND ASSESSMENT 10/29/2021 5/11/2021 4 TECHNICAL CAUAYAN CITY NATIONAL HIGH SCHOOL-RESEARCH ANNEX

INFORMATION AND COMMUNICATION TECHNOLOGY SERVICES-

VIRTUAL IN-SERVICE TRAINING FOR PUBLIC SCHOOL TEACHERS 03/15/2021 03/19/2021 40 TECHNICAL EDUCATIONAL TECHNOLOGY UNIT (ICTS-EdTech)

COMPUTER LITERACY 8/2/2021 10/2/2021 80 TECHNICAL TECHNICAL EDUCATION AND SKILLS

DEVELOPMENT AUTHORITY

FOOD AND BEVERAGE SERVICES 09/27/2019 11/22/2019 356 TECHNICAL TECHNICAL EDUCATION AND SKILLS
DEVELOPMENT AUTHORITY

(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)

Writing poems

Listening to Radio Dramas

(Continue on separate sheet if necessary)

SIGNATURE DATE February 27, 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? 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
MARVIN G. BALAGULAN BARCOLAN, GAMU, ISABELA 9190928186 3.5 cm. X 4.5 cm
(passport size)
MARINEL P. DAYAWON CENTRO 3, ANGADANAN, ISABELA 9514963785 With full and handwritten
name tag and signature over
PUROK 3, NUNGNUNGAN 1, CAUAYAN CITY, printed name
JONALYN G. BACANI ISABELA 9055990886
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
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable
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/License/Passport No.: 1825233

Signature (Sign inside the box)
February 27, 2024
Date/Place of Issuance: 12/29/2019/TUGUEGARAO CITY
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this 27th of February 2024 , affiant exhibiting his/her validly issued government ID as indicated above.

AMIEGRACE C. LIM
Administrative Officer IV/HRMO

Person Administering Oath

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