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 HERMOSA
NAME EXTENSION (JR., SR)
FIRST NAME DENNISE

MIDDLE NAME ARIOLA

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 02/23/1991 ✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH ISOK II, BOAC, MARINDUQUE If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS N/A N/A

Widowed Separated House/Block/Lot No. Street
N/A SAWI
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 1.79 BOAC MARINDUQUE
City/Municipality Province
8. WEIGHT (kg) 70 ZIP CODE 4900

18. PERMANENT ADDRESS N/A N/A

9. BLOOD TYPE AB+
House/Block/Lot No. Street

10. GSIS ID NO. N/A

N/A SAWI
Subdivision/Village Barangay
BOAC MARINDUQUE
11. PAG-IBIG ID NO. N/A
City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 4900

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

14. TIN NO. 275-334-638 20. MOBILE NO. 09994587850

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME HERMOSA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME JENNIFER JIA DENIQUE 0. HERMOSA 07/27/2016
MIDDLE NAME ORNEDO JUANCHO DOMINIC O. HERMOSA 01/20/2021

OCCUPATION TEACHER

EMPLOYER/BUSINESS NAME DEPED-MARINDUQUE

BUSINESS ADDRESS ISOK I, BOAC, MARINDUQUE

TELEPHONE NO. N/A

24. FATHER'S SURNAME HERMOSA

NAME EXTENSION (JR., SR)
FIRST NAME LARITO

MIDDLE NAME LARRACAS

25. MOTHER'S MAIDEN NAME

SURNAME ARIOLA

FIRST NAME EUGENIA

MIDDLE NAME MONLEON (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY SAWI ELEMENTARY SCHOOL ELEMENTARY 1998 2004 N/A 2004 3RD HONORABLE
MENTION

SECONDARY /
VOCATIONAL MARINDUQUE NATIONAL HIGH SCHOOL HIGH SCHOOL 2004 2008 N/A 2008 N/A

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

TRADE
BACHELOR OF SECONDARY EDUCATION MAJOR IN
COURSE
COLLEGE MARINDUQUE STATE COLLEGE MUSIC EDUCATION 2016 2019 N/A 2019 N/A

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

(Continue on separate sheet if necessary)

SIGNATURE DATE 11/19/2021

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

LICENSURE EXAMINATION FOR TEACHERS 85.2 09/29/2019 MARINDUQUE 1807192 02/23/2022

(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
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)
DEPARTMENT OF EDUCATION/DIVISION OF
05/21/2021 10/6/2021 SECONDARY SCHOOL TEACHER I MARINDUQUE/MATALABA NATIONAL HIGH SCHOOL
P23,877.00 11-1 SUBSTITUTE YES
DEPARTMENT OF EDUCATION/DIVISION OF
4/1/2021 03/30/2021 SECONDARY SCHOOL TEACHER I MARINDUQUE/ILAYA NATIONAL HIGH SCHOOL
P22,316.00 11-1 SUBSTITUTE YES

(Continue on separate sheet if necessary)

SIGNATURE DATE 11/19/2021

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
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

NATIONAL CERTIFICATE II (COMPUTER SYSTEMS SERVICING) 11/10/2019 11/22/2019 280 HOURS TECHNICAL MARINDUQUE TECHNICAL AND
VOCATIONAL INSTITUTE

(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 in
(Write in full)
full)

COMPUTER LITERATE N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 11/19/2021

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 ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘

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? ________________________________
________________________________
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
DR. REX EMMANUEL L. ASUNCION GASAN,MARINDUQUE 9052994882 4.5 cm. X 3.5 cm
(passport size)

ENGR. JEZHREEL L. SERRA LUPAC,BOAC,MARINDUQUE 9176075371

Computer generated
or photocopied picture
JOSE MARIE P. MITRA AMOINGON,BOAC,MARINDUQUE 9491963363 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 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 LICENSE
DENNISE A. HERMOSA
ID/License/Passport No.: 1807192
Signature (Sign inside the box)
11/19/2021
Date/Place of Issuance: 01-25-2020/LUCENA 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