VI.

VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES

29. NUM BER OF
(Write in full) (mm/dd/y y y y ) HOURS POSITION / NATURE OF WORK
From To

LOURDES COLLEGE TUTORIAL TEACHERS 13/06/2018 01/10/2018 30 HOURS TUTOR: TEACHING READING

COMMUNITY INVOLVEMENT PROGRAM (CIP) 01/06/2017 01/03/2018 40 HOURS SERVICE TO THE POOR

(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 o f LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE NUM BER OF ( M anagerial/ CONDUCTED/ SPONSORED BY
(Write in full) (mm/dd/y y y y ) HOURS Superviso ry/ (Write in full)
Technical/etc)
From To

ENGLISH PROFICIENCY SEMINAR 21/09/2017 21/09/2017 7 HOURS SPEAKER'S BUREAU

REGIONAL TEACHER EDUCATION CONGRESS 05/08/2017 05/08/2017 8 HOURS

CHED

ARTEKULTURA: WRITING CULTURE, ARTS RESEARCHES AND CRITICISM 08/08/2017 08/08/2017 6 HOURS
XAVIER UNIVERSITY
IN-SERVICE TRAINING (INSET) FOR JUNIOR AND SENIOR HIGH SCHOOL
MAY 15, 2017 MAY 17, 2017 24 HOURS
TEACHERS P R I VA T E ED U C A T I ON A S S I S T A N C E C OM M I T T EE

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

HOSTING/EMCEE SPEAKER'S BUREAU

MAKE-UP/BEAUTICIAN PERFORMING ARTS ORGANIZATION

World Council for Curriculum Instruction
DEBATER
(WCCI)
NEWS/RADIO BROADCASTER DEBATER'S CLUB

SCRIPT WRITER
PLAYWRIGHT FOR STAGE AND
PERFORMING THEATRE
CAMPUS JOURNALIST
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SIGNATURE DATE 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 YES NO
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,
YES NO
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 YES NO
Barangay election)? If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the YES NO
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? 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
PHOEBE L. BALABAG, PH. D BALINGASAG, MISAMIS ORIENTAL 0935-868-1239 3.5 cm. X 4.5 cm
(passport size)

LOU BRIGETTE JO, LPT BALINGASAG, MISAMIS ORIENTAL 0917-312-6880 With f ull and handwritten
name tag and signature ov er
printed name
JASMINE A. YAGAO, LPT BALINGASAG, MISAMIS ORIENTAL 0965-235-3328
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 administrative/criminal case/s PHOTO
against me.

Government Issued ID (i.e.P asspo rt, GSIS, SSS, P RC, Driver's

License, etc.) PLEASE INDICATE ID Number and
Gov ernment Issued ID: PRC ID

ID/License/Passport No.: 1600127

Signature (Sign inside the box )
OCTOBER 2018
Date/Place of Issuance: CAGAYAN DE ORO 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 (Rev ised 2017), Page 4 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
SEPTEMBER 24,
LICENSED PROFESSIONAL TEACHER 80.0 CAGAYAN DE ORO CITY 1600127 07/18/2020
2017

(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.
SALARY/ JOB/
28. INCLUSIVE DATES PAY GRADE (if
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GOV'T
(mm/dd/y y y y ) M ONTHLY applicable)& STA TUS OF
SERVICE
(Write in full/Do not abbrev iate) (Write in full/Do not abbrev iate) SA LA RY STEP (Format A P P OINTM ENT
(Y/ N)
" 00-0" )/
From To INCREM ENT
JUNE 01, MARCH 31, 1 YEAR
SHS FACULTY ST. RITA'S COLLEGE OF BALINGASAG 13, 000.00
2017 2018 CONTRACT
JUNE 01, OCTOBER SEMESTRAL
SHS FACULTY LOURDES COLLEGE 18, 000.00
2018 30, 2018 CONTRACT

(Continue on separate sheet if necessary)

SIGNATURE DATE CS FORM 212 (Revised 2017), Page 2 of 4

CS Form No. 212

PERSONAL DATA SHEET

Revised 2017

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 ACCOM PLISHING 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 ILAJAS
NAME EXTENSION (JR., SR)
FIRST NAME MARK ANTHONY
MIDDLE NAME VALLEDOR
3. DATE OF BIRTH
(mm/dd/y y y y )
JULY 18, 1993 16. CITIZENSHIP
Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH TABOK, LAGONGLONG, MISAMIS ORIENTAL If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female

6 CIVIL STATUS Single Married 17. RESIDENTIAL ADDRESS PUROK 1

Widowed Separated House/Block/Lot No. Street

Other/s:
TABOK
Subdivision/Village Barangay

7. HEIGHT (m) 1.5 LAGONGLONG MISAMIS ORIENTAL

City/Municipality Province
8. WEIGHT (kg) 56 ZIP CODE 9006

9. BLOOD TYPE AB 18. PERMANENT ADDRESS PUROK 1

House/Block/Lot No. Street

10. GSIS ID NO. TABOK

Subdivision/Village Barangay
LAGONGLONG MISAMIS ORIENTAL
11. PAG-IBIG ID NO. 1211-9797-7844
City/Municipality Province

12. PHILHEALTH NO. 15-050452984-5 ZIP CODE 9006

13. SSS NO. 08-2752235-0 19. TELEPHONE NO. N/A

14. TIN NO. 337-387-133 20. MOBILE NO. 0915-871-4681

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any ) [email protected]

II. FAMILY BACKGROUND

DATE OF BIRTH
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
(mm/dd/y y y y )
NA M E EXTENSION (JR., SR)
FIRST NAME 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 ILAJAS

FIRST NAME VALERIANO JR

MIDDLE NAME DY

25. MOTHER'S MAIDEN NAME

SURNAME VALLEDOR

FIRST NAME AMELITA

MIDDLE NAME REMELLETE (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

SCHOLA RSHI
P ERIOD OF
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE HIGHEST LEVEL/ YEA R P/
LEVEL A TTENDA NCE UNITS EA RNED GRA DUA TE A CA DEM IC
(Write in full) (Write in full) (if no t graduated) D HONORS
From To RECEIVED

JUNE 15, MARCH FOURTH

ELEMENTARY TABOK ELEMENTARY SCHOOL 2007
2001 31, 2007 HONORS
JUNE 13, MARCH THIRD
SECONDARY ST. JOHN THE BAPTIST HIGH SCHOOL 2011
2007 26, 2011 HONOR
VOCATIONAL /
TRADE COURSE
BACHELOR IN SECONDARY JUNE 08, MARCH DEAN'S
COLLEGE ST. RITA'S COLLEGE OF BALINGASAG 2017
EDUCATION MAJOR IN ENGLISH 2011 24, 2017 LISTER

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE CS FORM 212 (Rev ised 2017), Page 1 of 4