CS Form No.

212
Revised 2018
PERSONAL DATA SHEET
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 ACCOMPLISHING THE PDS FORM.
Print2018
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 HADJI IBRAHIM
FIRST NAME ROHANNAH NAME EXTENSION (JR., SR) N/A

MIDDLE NAME DITUCALAN

3. DATE OF BIRTH
(mm/dd/yyyy) 10/12/1996 16. CITIZENSHIP

SOMINUNGGAY, TAMPARAN LANAO DEL

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

6 CIVIL STATUS
17. RESIDENTIAL ADDRESS N.A N.A
House/Block/Lot No. Street
N.A SOMINUGGAY
Subdivision/Village Barangay
7. HEIGHT (m) 1.30 m TAMPARAN LANAO DEL SUR
City/Municipality Province
8. WEIGHT (kg) 42 kg ZIP CODE 9704
9. BLOOD TYPE N.A 18. PERMANENT ADDRESS N.A N.A
House/Block/Lot No. Street

10. GSIS ID NO. N.A N.A SOMINUGGAY

Subdivision/Village Barangay

11. PAG-IBIG ID NO. N.A TAMPARAN LANAO DEL SUR

City/Municipality Province

12. PHILHEALTH NO. N.A ZIP CODE 9704

13. SSS NO. N.A 19. TELEPHONE NO. N.A
14. TIN NO. N.A 20. MOBILE NO. 09072442282/09483232716
15. AGENCY EMPLOYEE NO. N.A 21. E-MAIL ADDRESS (if any) [email protected]
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 N/A N.A N.A
MIDDLE NAME N.A N.A N.A
OCCUPATION N.A N.A N.A
EMPLOYER/BUSINESS NAME N.A N.A N.A
BUSINESS ADDRESS N.A N.A N.A
TELEPHONE NO. N.A N.A N.A
24. FATHER'S SURNAME DITUCALAN N.A N.A
NAME EXTENSION (JR., SR)
FIRST NAME HADJI IBRAHIM N/A N.A N.A
MIDDLE NAME HADJI MOHAMMAD N.A N.A
25. MOTHER'S MAIDEN NAME MELIC N.A N.A
SURNAME DITUCALAN N.A N.A
FIRST NAME MELIC N.A N.A
MIDDLE NAME MACALABO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL HIGHEST LEVEL/
26. PERIOD OF ATTENDANCE YEAR SCHOLARSHIP/
BASIC EDUCATION/DEGREE/COURSE UNITS
LEVEL (Write in EARNED
GRADUATED ACADEMIC HONORS
(Write in full) RECEIVED
full) (if not graduated)
From To

TAMPARAN CENTRAL PILOT Third honorable

ELEMENTARY ELEMENTARY 2003 2009 - 2009
ELEMENTARY SCHOOL mention
DATU PALAWAN DISOMIMBA MEMORIAL
SECONDARY /
VOCATIONAL SECONDARY 2009 2013 - 2013 N.A
NATIONAL HIGH SCHOOL

TESDA COMPUTER LITERACY 2017 2018 2018 N.A

TRADE
COURSE SENATOR NINOY AQUINO COLLEGE BACHELOR IN ELEMENTARY
COLLEGE 2013 2017 - 2017 WITH HONOR
FOUNDATION - MARAWI CITY 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 APRIL 02, 2019 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
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity
R.A. 1080 ( LICENSURE EXAMINATION FOR
78.4 03/25/2018 CAGAYAN DE ORO CITY 1669833 10/12/2021
TEACHERS)

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(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 SERVICE
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY SALARY/ JOB/ PAY
(mm/dd/yyyy) MONTHLY GRADE (if applicable)& STATUS OF
(Write in full/Do not SALARY STEP (Format "00-0")/ APPOINTMENT
abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To
(Y/ N)
AS-SALIHIEN INTEGRATED SCHOOL
6/1/2018 03/28/2019 FACULTY MEMBER 5500.00 N.A N.A N.A
FOUNDATION INC.
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(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 02, 2019 CS FORM 212 (Revised 2018), 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

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(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
ATTENDANCE Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To
1ST TEACHERS EDUCATION INSTITUTIONS, LEADERSHIP WORKSHOP "ENHANCING
LEADERSHIP SKILLS OF EDUCATORS FOR BETTER AND EFFECTIVE GOVERNANCE"
09/302016 10/01/2016 16 HOURS TECHNICAL MINDANAO STATE UNIVERSITY-MARAWI CITY
YOUTH LEADERS CONFERENCE AND TRAINING WORKSHOP "YOUTH: THE PROPONENTS FOR
POSITIVE SOCIAL CHANGE AND THE TOOLS FOR PEACE AND DEVELOPMENT"
11/12/2016 11/12/2016 8 HOURS TECHNICAL MINDANAO STATE UNIVERSITY-MARAWI CITY
SEMINAR WORKSHOP TRAINING ON ISLAMIC LEADERSHIP "MUSLIM YOUTH: THE SWORD TO SENATOR NINOY AQUINO COLLEGE
FORFEND THE ISLAMIC WAY OF LEADERSHIP" 07/24/2016 07/24/2016 8 HOURS TECHNICAL
FOUNDATION
GLOBALIZATION SEMINAR "THE JOURNEY OF 21ST CENTURTY TEACHERS IN
09/23/2016 09/23/2016 7 HOURS TECHNICAL PHILIPPINES MUSLIM TEACHERS' COLLEGE
GLOBAL VILLAGE"
LECTURE-SEMINAR ON THE TOPIC TRANCEFORMATIVE EDUCATION "MAINSTREAMING STUDENTS SENATOR NINOY AQUINO COLLEGE
TOWARDS THE CHALLENGES OF THE SOCIETAL CHANGE) 02/25/2016 02/25/2016 4 HOURS TECHNICAL
FOUNDATION
SENATOR NINOY AQUINO COLLEGE
ORIENTATION-SEMINAR ON K+12 "K to 12 TOWARDS QUALITY EDUCATION" 05/04/2016 05/04/2016 4 HOURS TECHNICAL
FOUNDATION
SEMINAR ON ANTI-BULLYING "EMERGE THE YOUNG GENERATION TO BREAK JAMIATU PHILIPPINE AL-ISLAMIA , MARAWI
04/03/2016 04/03/2016 4 HOURS TECHNICAL
THE ACT OF BULLYING CITY
ALLIANCE OF MUSLIM YOUTH STUDENTS '' LOVE AND CARE IN ISLAM'' AND THE
06/21/2016- 06/21/2016 4 HOURS TECHNICAL MINDANAO STATE UNIVERSITY-MARAWI CITY
TRUE FISABILILLAH
ALLIANCE OF MUSLIM YOUTH STUDENTS '' THE SWORD TO PROFEND THE
07/24/2016 07/214/2016 4HOURS TECHNICAL MINDANAO STATE UNIVERSITY-MARAWI CITY
ISLAMIC WAY OF LEADERSHIP ''
ORIENTATION-SEMINAR ON WHAT EDUCATION STUDENTS NEED TO KNOW SENATOR NINOY AQUINO COLLEGE
5/3/2015 5/3/2015 8 HOURS TECHNICAL
ABOUT THIER CHOOSEN FIELD FOUNDATION
SENATOR NINOY AQUINO COLLEGE
ISLAMIC SEMINAR : THE SIGNIFICANCE OF RAMADHAN 07/ 25 / 2013 07/25/2013 9 HOURS TECHNICAL
FOUNDATION
SENATOR NINOY AQUINO COLLEGE
ACTIVITY CONDUCT OF CLEAN-UP DRIVE 01/23/2014 1/1/2023 9 HOURS TECHNICAL
FOUNDATION
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(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

TEACHING N/A N/A

COMPUTER LITERATE N/A N/A

DANCING N/A N/A

READING BOOKS N/A N/A

__ N/A N/A

__ N/A N/A

__ N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 02, 2019 CS FORM 212 (Revised 2018), 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)

ID picture taken within
NAME ADDRESS TEL. NO. the last 6 months
3.5 cm. X 4.5 cm
(passport size)
___ __ __
With full and handwritten
name tag and signature over
___ __ __ printed name

Computer generated
___ __ __ or photocopied picture
is not acceptable
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 PHOTO
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/License/Passport No.: 1669833 Signature (Sign inside the box)

Date/Place of Issuance: 09/27/2018- CAGAYAN DE ORO

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 2018), Page 4 of 4