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

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.

I. PERSONAL INFORMATION

2. SURNAME GALANZA

FIRST NAME RENE

MIDDLE NAME TAMONAN

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 8/19/1995 ✘ Filipino Dual C

HOME DELIVERY, AYANGAN, JORDAN,

4. PLACE OF BIRTH If holder of dual citizenship,
GUIMARAS
please indicate the details.
5. SEX ✘ Male Female

17. RESIDENTIAL ADDRESS

6 CIVIL STATUS ✘ Single Married
House/Block/Lot No.
Widowed Separated
Other/s: Subdivision/Village
7. HEIGHT (m) 1.5 SIBUNAG
City/Municipality
8. WEIGHT (kg) 38 ZIP CODE 5048
18. PERMANENT ADDRESS
9. BLOOD TYPE B
House/Block/Lot No.

10. GSIS ID NO. NONE

Subdivision/Village
SIBUNAG
11. PAG-IBIG ID NO. 121187827298
City/Municipality

12. PHILHEALTH NO. 11-252727647-3 ZIP CODE 5048

13. SSS NO. 07-3601578-3 19. TELEPHONE NO. NONE

14. TIN NO. 333 758 628 20. MOBILE NO. 09974692930 / 0

15. AGENCY EMPLOYEE NO. NONE 21. E-MAIL ADDRESS (if any)
Rene_Galanza@
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME NONE 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) NONE
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME GALANZA

NAME EXTENSION (JR., SR)
FIRST NAME RICHARD

MIDDLE NAME FERNANDEZ

25. MOTHER'S MAIDEN NAME

SURNAME TAMONAN

FIRST NAME LANIE

MIDDLE NAME CAPILLO (Continue on separate s

III. EDUCATIONAL BACKGROUND

26. NAME OF SCHOOL PERIOD OF ATTENDANCE

BASIC EDUCATION/DEGREE/COURSE
LEVEL (Write in
(Write in full)
full)
 NAME OF SCHOOL
BASIC EDUCATION/DEGREE/COURSE
LEVEL (Write in
(Write in full)
full)
From To

ELEMENTARY AYANGAN ELEMENTARY SCHOOL ELEMENTARY 2002 2008

SECONDARY AYANGAN NATIONAL HIGH SCHOOL HIGH SCHOOL 2008 2012

VOCATIONAL /

NONE
TRADE
COURSE

BACHELOR OF SECONDARY
COLLEGE GUIMARAS STATE COLLEGE EDUCATION MAJOR IN 2012 2016
MATHEMATICS

GRADUATE STUDIES NONE

(Continue on separate sheet if necessary)
SIGNATURE DATE
AL DATA SHEET
erience Sheet shall cause the filing of administrative/criminal case/s against the person concerned.

EFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

✘ Filipino Dual Citizenship

by birth by naturalization
Pls. indicate country:

SITIO POBLACION
Street
AYANGAN
Barangay
GUIMARAS
Province
5048
SITIO POBLACION
Street
AYANGAN
Barangay
GUIMARAS
Province

5048

NONE

09974692930 / 09123756535

[email protected]

23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

NONE

(Continue on separate sheet if necessary)

HIGHEST LEVEL/
YEAR
UNITS SCHOLARSHIP/ ACADEMIC
GRADUATED
EARNED HONORS RECEIVED
(if not graduated)
 HIGHEST LEVEL/
YEAR
UNITS SCHOLARSHIP/ ACADEMIC
GRADUATED
EARNED HONORS RECEIVED
(if not graduated)

2008 SALUTATORIAN

2012 VALEDICTORIAN

ACADEMIC AND
BARANGAY
2016
SCHOLAR / CUM
LAUDE

n separate sheet if necessary)

June 5, 2018
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27.
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable)
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

LET (LICENSURE EXAMINATION FOR

82.0 9/25/2016 ILOILO DOCTOR'S COLLEGE
TEACHERS)

(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
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(Write in full/Do not (Write in MONTHLY SALARY applicable)& STEP
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To

EUCHARISTIC KING ACADEMY OF

6/14/2017 3/31/2018 CLASSROOM TEACHER Php 7, 300.00 N/A
SARA, INC.

6/8/2016 10/26/2016 CONTRACTUAL INSTRUCTOR GUIMARAS STATE COLLEGE Php 8,000.00 N/A

SUMMER CLASS MATHEMATICS

4/20/2016 5/6/2016 GUIMARAS BAPTIST ACADEMY Php 6,500.00 N/A
TEACHER
 (Continue on separate sheet if necessary)

SIGNATURE DATE 06/05/2018

CS FOR
 LICENSE (if applicable)

NUMBER
Date of
Validity

1521084 8/19/2020

on separate sheet if necessary)

duties should be indicated in the attached Work Experience sheet.

GOV'T
SERVICE

STATUS OF
APPOINTMENT

(Y/
N)

PROBATIONARY N

CONTRACTUAL Y

CONTRACTUAL N
on separate sheet if necessary)

06/05/2018
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

INCLUSIVE DATES
NAME & ADDRESS OF ORGANIZATION
29. (mm/dd/yyyy) NUMBER OF HOURS
(Write in full)
From To

NONE

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 ATTENDANCE

Type of LD
TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ( Managerial/
30. (mm/dd/yyyy) NUMBER OF HOURS
Supervisory/ CONDUCT
(Write in full)
Technical/etc)
From To

DEPART
2018 SUMMER DEPED-PEAC IN-SERVICE TRAINING (INSET) 4/30/2018 5/2/2018 24.0 MANAGERIAL
ASSISTA

DIWA LEA
DIWA INNOVATORS CONGRESS 11/11/2017 11/11/2017 8.0 MANAGERIAL
FOUNDAT

2017 DIVISION MATH MIX FEVER 11/3/2017 11/5/2017 72.0 MANAGERIAL SCHOOL

GUIMARA
STUDENTS TEACHERS' SEMINAR IN EDUCATIONAL TECHNOLOGY 3/21/2016 3/21/2016 3.0 TECHNICAL
EDUCATIO

GUIMARA
STUDENTS TEACHERS' SEMINAR IN TRENDS, ISSUES, AND UPDATES 3/21/2016 3/21/2016 3.0 TECHNICAL
EDUCATIO

STUDENTS TEACHERS' SEMINAR IN EDUCATION (TALENT AND SKILLS FOR GUIMARA

3/11/2016 3/11/2016 3.0 TECHNICAL
FUTURE EDUCATORS) EDUCATIO

STUDENTS TEACHERS' SEMINAR IN TECHNOLOGY AND LIVELIHOOD GUIMARA

3/11/2016 3/11/2016 3.0 TECHNICAL
EDUCATION EDUCATIO

GUIMARA
STUDENTS TEACHERS' SEMINAR IN SOCIAL STUDIES 2/26/2016 2/26/2016 3.0 TECHNICAL
EDUCATIO

PHILIPPINES ASSOCIATION FOR TEACHERS AND EDUCATORS VI REGIONAL PHILIPPI

2/18/2016 2/20/2016 24.0 MANAGERIAL
STUDENTS' CONGRESS EDUCAT

GUIMARA
STUDENTS TEACHERS' SEMINAR IN MATHEMATICS 2/12/2016 2/12/2016 3.0 TECHNICAL
EDUCATIO

GUIMARA
STUDENTS TEACHERS' SEMINAR IN SCIENCE 2/5/2016 2/5/2016 3.0 TECHNICAL
EDUCATIO

GUIMARA
STUDENTS TEACHERS' SEMINAR IN FILIPINO 1/29/2016 1/29/2016 3.0 TECHNICAL
EDUCATIO

GUIMARA
STUDENTS TEACHERS' SEMINAR IN ENGLISH 1/22/2016 1/22/2016 3.0 TECHNICAL
EDUCATIO

GUIMARA
STUDENTS TEACHERS' SEMINAR IN PROFESSIONAL EDUCATION 1/22/2016 1/22/2016 3.0 TECHNICAL
EDUCATIO

GUIMARA
3-DAY ORIENTATION SEMINAR AND WORKSHOP ON STUDENT TEACHING 11/11/2015 11/13/2015 24.0 TECHNICAL
EDUCATIO

LEADERSHIP TRAINING 8/26/2015 8/26/2015 8.0 TECHNICAL GUIMAR

39TH YOUNG MEN'S CHRISTIAN ASSOCIATION NATIONAL CONGRESS OF

12/3/2014 12/7/2014 40.0 MANAGERIAL YOUNG
COLLEGE STUDENTS

COMPUTER LITERACY PROGRAM 11/24/2011 3/24/2012 640.0 TECHNICAL MUNICIP

VIII. OTHER INFORMATION

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

LETTERING SERVICE AWARD - GUIMARAS STATE COLLEGE YOUTH

DRAWING

EXPLORING/SURFING THE NET

USING COMPUTER

SIGNATURE DATE
PLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

MS ATTENDED

years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY (Write in full)

DEPARTMENT OF EDUCATION- PRIVATE EDUCATION

ASSISTANCE COMMITTEE

DIWA LEARNING SYSTEMS INCORPORATED and BATO BALANI

FOUNDATION INCORPORATED

SCHOOLS DIVISION OF ILOILO

GUIMARAS STATE COLLEGE - COLLEGE OF TEACHER

EDUCATION

GUIMARAS STATE COLLEGE - COLLEGE OF TEACHER

EDUCATION

GUIMARAS STATE COLLEGE - COLLEGE OF TEACHER

EDUCATION

GUIMARAS STATE COLLEGE - COLLEGE OF TEACHER

EDUCATION

GUIMARAS STATE COLLEGE - COLLEGE OF TEACHER

EDUCATION

PHILIPPINE ASSOCIATION FOR TEACHERS AND

EDUCATORS VI

GUIMARAS STATE COLLEGE - COLLEGE OF TEACHER

EDUCATION

GUIMARAS STATE COLLEGE - COLLEGE OF TEACHER

EDUCATION

GUIMARAS STATE COLLEGE - COLLEGE OF TEACHER

EDUCATION

GUIMARAS STATE COLLEGE - COLLEGE OF TEACHER

EDUCATION

GUIMARAS STATE COLLEGE - COLLEGE OF TEACHER

EDUCATION

GUIMARAS STATE COLLEGE - COLLEGE OF TEACHER

EDUCATION

GUIMARAS STATE COLLEGE

YOUNG MEN'S CHRISTIAN ASSOCIATION OF MANILA

MUNICIPALITY OF SIBUNAG
 MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in full)

YOUTH MINISTRY OF OUR LADY OF LOURDES PARISH

JUNE 5, 2018

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
YES ✘ NO
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? ________________________________
FINISHED CONTRACT/VOLUNTARY RESIGNATION
________________________________
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
ROSALIE G. GAMARCHA AYANGAN, SIBUNAG, GUIMARAS N/A 3.5 cm. X 4.5 cm
(passport size)

VICTORIA T. GALVE AYANGAN, SIBUNAG, GUIMARAS N/A With full and handwritten
name tag and signature over
printed name
SOL G. YDULLAN NUEVA VALENCIA, GUIMARAS 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/License/Passport No.: 1521084 Signature (Sign inside the box)
JUNE 5, 2018
Date/Place of Issuance: 1-6-17/PRC ILOILO 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 o

 FINISHED CONTRACT/VOLUNTARY RESIGNATION

If YES, give details (country):

, affiant exhibiting his/her validly issued government ID as indicated above.

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