CS Form No.

212
PERSONAL DATA SHEET
Revised 2017

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.
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 PELEGRINO
NAME EXTENSION (JR., SR) NA
FIRST NAME MARIFE
MIDDLE NAME BALUYOT
3. DATE OF BIRTH
(mm/dd/yyyy) 07/10/1987 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH LAOANG, NORTHERN SAMAR If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS PUROK 2 N/A

Widowed Separated House/Block/Lot No. Street
N/A ROMBANG
Other/s:
Subdivision/Village Barangay
LAOANG NORTHERN SAMAR
7. HEIGHT (m) 1.51
City/Municipality Province
8. WEIGHT (kg) 60 ZIP CODE 6411

18. PERMANENT ADDRESS PUROK 2 N/A

9. BLOOD TYPE "A"
House/Block/Lot No. Street
N/A ROMBANG
10. GSIS ID NO. 2005447737
Subdivision/Village Barangay
LAOANG NORTHERN SAMAR
11. PAG-IBIG ID NO. 1211-0911-9710
City/Municipality Province

12. PHILHEALTH NO. 13-000125108-3 ZIP CODE 6411

13. SSS NO. 34-0091355-8 19. TELEPHONE NO. N/A

14. TIN NO. 252-714-798-000 20. MOBILE NO. 09773127852

15. AGENCY EMPLOYEE NO. 6302094 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME BECUÑA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) N/A BECUÑA, JEZNIEL DAVE
FIRST NAME ADONIS 11/17/2012

MIDDLE NAME NUNGAY BECUÑA, JAZCELLE DEVONNE 08/17/2015

OCCUPATION HABAL-HABAL DRIVER BECUÑA, JARED DENIEL 01/02/2018

EMPLOYER/BUSINESS NAME N/A BECUÑA, DENVER JUDE 09/09/2020

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME PELEGRINO

NAME EXTENSION (JR., SR) N/A
FIRST NAME CORNELIO

MIDDLE NAME TURLA

25. MOTHER'S MAIDEN NAME

SURNAME BALUYOT

FIRST NAME AUREA

MIDDLE NAME CERBITO

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
(Write in full) HONORS
full) (if not graduated) RECEIVED
From To

ELEMENTARY LAOANG I CENTRAL ELEMENTARY SCHOOL ELEMENTARY 06/01/1994 04/01/2000 N/A 2000 N/A

VOCATIONAL
SECONDARY / LAOANG NATIONALTECHNICAL HIGH SCHOOL HIGH SCHOOL 06/01/2000 04/01/2004 N/A 2004

N/A N/A N/A N/A N/A N/A N/AN/A

TRADE UNIVERSITY OF EASTERN PHILIPPINES, MAIN
COLLEGE
COURSE CAMPUS
BACHELOR OF SCIENCE IN MATHEMATICS 06/01/2004 04/01/2010 N/A 2010 N/A

PROFESSIONAL TEACHER CERTIFICATE

NORTHERN SAMAR COLLEGES
PROGRAM
11/01/2014 04/01/2015 N/A 2015 N/A

UNIVERSTY OF EASTERN PHILIPPINES, LAOANG MASTER OF ARTS IN MATHEMATICS

GRADUATE STUDIES
CAMPUS EDUCATION
08/27/2023 PRESENT N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 03/15/2024 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
UNIVERSITY OF EASTREN PHILIPPINES-
LICENSURE EXAM FOR TEACHERS 75.0 9/27/2015 1469375 10/7/2025
CATARMAN, NORTHERN SAMAR

(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 (Write in SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
full/Do not abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)
E.J. DULAY NATIONAL HIGH SCHOOL -
01/01/2024 PRESENT TEACHER I 27,284.00 11-2 PERMANENT Y
DEPARTMENT OF EDUCATION
E.J. DULAY NATIONAL HIGH SCHOOL -
01/01/2023 12/31/2023 TEACHER I 27,284.00 11-2 PERMANENT Y
DEPARTMENT OF EDUCATION
E.J. DULAY NATIONAL HIGH SCHOOL -
01/01/2022 12/31/2022 TEACHER I 25,723.00 11-2 PERMANENT Y
DEPARTMENT OF EDUCATION
E.J. DULAY NATIONAL HIGH SCHOOL -
06/29/2021 12/31/2021 TEACHER I 24,161.00 11-2 PERMANENT Y
DEPARTMENT OF EDUCATION
E.J. DULAY NATIONAL HIGH SCHOOL -
01/01/2021 06/28/2021 TEACHER I 23,887.00 11-1 PERMANENT Y
DEPARTMENT OF EDUCATION
E.J. DULAY NATIONAL HIGH SCHOOL -
01/01/2020 12/31/2020 TEACHER I 22,316.00 11-1 PERMANENT Y
DEPARTMENT OF EDUCATION
E.J. DULAY NATIONAL HIGH SCHOOL -
01/01/2019 12/31/2019 TEACHER I 20,754.00 11-1 PERMANENT Y
DEPARTMENT OF EDUCATION
E.J. DULAY NATIONAL HIGH SCHOOL -
08/31/2018 12/31/2018 TEACHER I 20,179.00 11-1 PERMANENT Y
DEPARTMENT OF EDUCATION
LAS NAVAS NATIONAL HIGH SCHOOL -
06/29/2018 08/30/2018 TEACHER I 20,179.00 11-1 PERMANENT Y
DEPARTMENT OF EDUCATION

(Continue on separate sheet if necessary)

SIGNATURE DATE 03/15/2024 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

(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
HIGHER ORDER THINKING SKILLS PROFESSIONAL LEARNING PACKAGES(HOTS-PLPs)
12/032023 12/06/2023 32 HOURS TECHNICAL DIVISION OF NORTHERN SAMAR
FOR SCIENCE GRADE 9 AND 10 TEACHERS

(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)

COMPUTER LITERATE N/A N/A

READING

DANCING

SINGING

(Continue on separate sheet if necessary)

SIGNATURE DATE 03/15/2024 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 NO
YES ✘
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? ________________________________
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.

JESSA L. SIERVO PAMBUJAN, NORTHERN SAMAR 9955688097

MA. ERICA R. POSO LAOANG, NORTHERN SAMAR 9678760249

JOHN REY P. PAJANTOY PALAPAG, NORTHERN SAMAR 9606608655

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.: 1469375

Signature (Sign inside the box)
03/15/2024
Date/Place of Issuance: TACLOBAN
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