CSAForm 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 SUMAGDON

FIRST NAME RYAN NAME EXTENSION (JR., SR)

MIDDLE NAME MACABIDANG

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) OCTOBER 01, 1999 ✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH BRGY. SAN ISIDRO GANDARA SAMAR FILIPINO Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

✘ Single Married 17. RESIDENTIAL ADDRESS N/A N/A

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
N/A SAN ISIDRO
Other/s:
Subdivision/Village Barangay
GANDARA SAMAR
7. HEIGHT (m) 151
City/Municipality Province
8. WEIGHT (kg) 55kgs ZIP CODE

9. BLOOD TYPE O+ 18. PERMANENT ADDRESS N/A N/A

House/Block/Lot No. Street
N/A SAN ISIDRO
10. GSIS ID NO. N/A
Subdivision/Village Barangay
GANDARA SAMAR
11. PAG-IBIG ID NO. N/A
City/Municipality Province
12. PHILHEALTH NO. N/A ZIP CODE 6706
13. SSS NO. N/A 19. TELEPHONE NO. N/A
14. TIN NO. N/A 20. MOBILE NO. 09272571668
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)

FIRST NAME N/A AREIL E. SUMAGDON 08/23/1980

MIDDLE NAME N/A MARIAN M. SUMAGDON 03/14/ 1983
MARVIN M. SUMAGDON
OCCUPATION N/A 07/29/2001
ALDOMER M. SUMAGDON
EMPLOYER/BUSINESS NAME N/A 08/16/2003
EDRIAN M. SUMAGDON
BUSINESS ADDRESS N/A 02/03/2006
TELEPHONE NO. N/A YILMAR M. SUMADON 03/19/2008
ALJUN M. SUMAGDON
24. FATHER'S SURNAME SUMAGDON 11/9/2011
ARIANA MAE M. SUAMAGDON
FIRST NAME AREIL 08/14/2014

MIDDLE NAME ESCAL

25. MOTHER'S MAIDEN NAME

SURNAME MACABIDANG

FIRST NAME MARIAN

MIDDLE NAME FEDELIZA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY GANDARA I CENTRAL ELEMENTARY SCHOOL PRIMARY EDUCATION 2007 2013 GRADUATE 2013 WITH HONOR

JUNIOR HIGH SCHOOL RAMON T. DIAZ NATIONAL HIGH SCHOOL HIGH SCHOOL 2013 2016 COMPLETED 2016 WITH HONOR
SENIOR HIGH
SCHOOL
RAMON T. DIAZ NATIONAL HIGH SCHOOL HUMANITIIES AND SOCIAL SCIENCES 2016 2019 GRADUATE 2019 WITH HONOR

BACHELOR TECHNICAL VOCATIONAL

COLLEGE SAMAR STATE UNIVERSITY MERCEDES CAMPUS
TEACHER EDUCATION
2019 2023 N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE January 30, 2023
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

N/A

(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)

N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 30, 2023

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

(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. ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

N/A

(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)

N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 30. 2023

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? ✘ NO
YES
b. within the fourth degree (for Local Government Unit - Career Employees)? ✘ NO
YES
If YES, give details: ________________________________
________________________________

35. a. Have you ever been found guilty of any administrative offense? ✘ NO
YES
If YES, give details: ________________________________
________________________________

b. Have you been criminally charged before any court? ✘ NO

YESgive details: ________________________________
If YES,
________________________________
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?
✘ NO
YESgive details: ________________________________
If YES,
________________________________

37. Have you ever been separated from the service in any of the following modes: resignation, ✘ NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased YESgive details: ________________________________
If YES,
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)?
✘ NO
YESgive details:
If YES,
b. Have you resigned from the government service during the three (3)-month period before the last ✘ NO
election to promote/actively campaign for a national or local candidate? YES
If YES, give details:
39. Have you acquired the status of an immigrant or permanent resident of another country?
✘ NO
YESgive details (country):
If YES,

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? ✘ NO
If YES,YES
please specify:
b. Are you a person with disability? ✘ NO
If YES,YES
please specify ID No:
c. Are you a solo parent? ✘ NO
If YES,YES
please specify ID No:

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAME ADDRESS TEL. NO./CEL.NO.

ID picture taken within
the last 6 months
ARMINGOL A. LAPACIONES BRGY. SAN ISIDRO 9365310526 3.5 cm. X 4.5 cm
(passport size)

EDELYN M. FEDELIZA BRGY. ADELA HIEGHTS 9125930328 With full and handwritten
name tag and signature over
printed name
MARK DEXTER M. LAPACIONES BRGY. SAN ISIDRO 9107507088
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: N/A

ID/License/Passport No.: N/A

Signature (Sign inside the box)
JANUARY 30, 2023
Date/Place of Issuance: N/A
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