CS Form No.

212

PERSONAL DATA SHEET

Revised 2017

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 CARIAGA
NAME EXTENSION (JR., SR) N/A
FIRST NAME DOMINGA RIO
MIDDLE NAME COBRE
3. DATE OF BIRTH
01/14/1990 16. CITIZENSHIP
(mm/dd/yyyy)

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

17. RESIDENTIAL ADDRESS

6 CIVIL STATUS
House/Block/Lot No. Street

SEPARATED
N/A SUMADEL

Subdivision/Village Barangay
TADIAN MOUNTAIN PROVINCE
7. HEIGHT (m) 1.47
City/Municipality Province

8. WEIGHT (kg) 64 ZIP CODE 2620

18. PERMANENT ADDRESS N/A N/A

9. BLOOD TYPE O
House/Block/Lot No. Street
SUMADEL
10. GSIS ID NO. N/A
Subdivision/Village Barangay
TADIAN MOUNTAIN PROVINCE
11. PAG-IBIG ID NO. N/A
City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 2620

13. SSS NO. N/A 19. TELEPHONE NO. NONE

14. TIN NO. N/A 20. MOBILE NO. 9070477835

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME CARIAGA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

NAME EXTENSION(JR.,SR) N/A

FIRST NAME NICO RHEIN KURT COBRE CARIAGA 09/15/2013

MIDDLE NAME KAWI ELLE COBRE CARIAGA 05/29/2019

OCCUPATION LABORER
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME COBRE
NAME EXTENSION (JR., SR)
FIRST NAME MARTIN N/A

MIDDLE NAME ABAYA

25. MOTHER'S MAIDEN NAME

SURNAME TAYAB
FIRST NAME CECELIA

MIDDLE NAME SALIW-AN (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY SUMADEL ELEMENTARY SCHOOL ELEMENTARY 1997 2003 N/A 2003 N/A

SECONDARY /
VOCATIONAL MASLA NATIONAL HIGH SCHOOL HIGH SCHOOL 2003 2007 N/A 2007 N/A

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

TRADE MOUNTAIN PROVINCE POLYTECHNIC BACHELOR IN ELEMENTARY
COLLEGE
COURSE 2009 2013 N/A 2017 NCIP-GRANTEE
COLLEGE-TADIAN 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 CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY
LICENSE (if applicable)
27 CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL RATING
DATE OF
LAWS/ CES/ CSEE BARANGAY EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable)
ELIGIBILITY / DRIVER'S LICENSE CONFERMENT NUMBER Date of
Validity

LICENSURE EXAMINATION FOR TEACHER (LET) 75% 1/3/2015 BAGUIO CENTRAL SCHOOL 1384207 01/14/2025

(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
SALARY/ JOB/ PAY
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
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)

02/24/2017 03/23/2017 Teacher 1 Department of Education 18,000.00 11 Substitute Y

01/18/2017 02/16/2017 Teacher 1 Department of Education 18,000.00 11 Substitute Y

(Continue on separate sheet if necessary)

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

03/31/2013 04/02/2023 24 TECHNICAL Center for the Professional Advancement of Educators

National Seminar-Workshop on Effective Teaching to Support Low Achieving Learners

5 - Day School- Based-In-Service Training -Workshop on Revising T.O.S Making, Text- 02/06/2023 02/10/2023 40 TECHNICAL Sumadel Elementary School
Construction and Analysis cum Learning Package Preparation and IPCRF Mid-year Review

(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 full)
(Write in full)

Teaching N/A

Computer literate

(Continue on separate sheet if necessary)

SIGNATURE DATE CS FORM 212 (Revised 2017), Page 3 of 4

5/3/2024
 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:

Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation
36.
by any court or tribunal?
If YES, give details:
________________________________
________________________________

Have you ever been separated from the service in any of the following modes: resignation,
37. retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased
out (abolition) in the public or private sector?
If YES, give details:
________________________________
________________________________

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:

Have you acquired the status of an immigrant or permanent resident of another country?
39.

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: APPLAI
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)

NAME ADDRESS TEL. NO. ID picture taken within
the last 6 months
ARTHUR D. LUMINO SUMADEL ,TADIAN 9103905249 3.5 cm. X 4.5 cm
(passport size)
JUDITH C. YAPES SUMADEL ,TADIAN 9505112742 With full and handwritten
name tag and signature over
printed name

Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete or photocopied picture
statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. I is not acceptable
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.: 1384207 Signature (Sign inside the box)
03/05/2024
Date/Place of Issuance: 07/13/2017 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