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 DE CLARO
NAME EXTENSION (JR., SR) N/A
FIRST NAME ROJAYRA

MIDDLE NAME DIMAUNAHAN

3. DATE OF BIRTH
(mm/dd/yyyy) 01/16/1998 16. CITIZENSHIP
✘

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

6 CIVIL STATUS ✘ 17. RESIDENTIAL ADDRESS N/A NARRA STREET

House/Block/Lot No. Street
N/A CABOG-CABOG
Subdivision/Village Barangay
7. HEIGHT (m) 1.52 BALANGA CITY BATAAN
City/Municipality Province
8. WEIGHT (kg) 60 KGS ZIP CODE 2100

9. BLOOD TYPE O+
18. PERMANENT ADDRESS N/A NARRA STREET
House/Block/Lot No. Street
10. GSIS ID NO. 2006388908
N/A CABOG-CABOG
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1212-6981-5957 BALANGA CITY BATAAN

City/Municipality Province

12. PHILHEALTH NO. 07-201853997-8 ZIP CODE 2100

13. SSS NO. 34-9409190-7 19. TELEPHONE NO. N/A

14. TIN NO. 634-589-997-00000 20. MOBILE NO. 09859732453/09668839926

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME DE CLARO 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR.,
FIRST NAME LEONARDO SR) N/A SEAN JAYNARD D. DE CLARO 5/1/2015

MIDDLE NAME BIENES

OCCUPATION MECHANIC

EMPLOYER/BUSINESS NAME MOTORTRADE

BUSINESS ADDRESS PILAR, BATAAN

TELEPHONE NO. N/A

24. FATHER'S SURNAME DIMAUNAHAN

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

MIDDLE NAME GAMIER

25. MOTHER'S MAIDEN NAME

SURNAME QUIMZON

FIRST NAME WENA

MIDDLE NAME CURIBA (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
DR. VICTORIA B. ROMAN MEMORIAL HIGH
ELEMENTARY SCHOOL
PANTINGAN ELEMENTARY SCHOOL PRIMARY 6/7/2004 03/20/2010 GRADUATED 2010 N/A

SECONDARY /
VOCATIONAL SECONDARY 6/7/2010 03/20/2014 GRADUATED 2014 N/A

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

TRADE
BATAAN PENINSULA STATE UNIVERSITY BACHELOR OF SECONDARY
COURSE
COLLEGE 10/7/2014 12/21/2020 GRADUATED 2020 N/A
(BALANGA CAMPUS) EDUCATION

N/A N/A N/A N/A N/A N/A 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
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 PROFESSIONAL
79.0 09/26/2021 BAGUIO CITY 1907418 01/16/2025
TEACHERS

(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)
DR. VICTORIA B ROMAN MEMORIAL HIGH SG-11,
09/25/2023 PRESENT TEACHER I 27000.00 CONTRACTUAL YES
SCHOOL (JHS) STEP-1

(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

DR. VICTORIA B. ROMAN MEMORIAL HIGH SCHOOL 12/5/2022 7/1/2023 VOLUNTEER TEACHER

(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

BASIC COMPUTER LITERACY 3/27/2023 6/4/2023 80Hrs TECHNICAL ELTECH LEARNING HUB

SCHOOL INSET: INSET ON ACTION RESEARCH , INNOVATIONS, TEACHING PEDAGOGIES

6/2/2023 7/2/2023 16Hrs TECHNICAL DR. VICTORIA B. ROMAN MEMORIAL HIGH SCHOOL
AND CLASSROOM MANAGEMENT
PRODUCTION OF HIGH- QUALITY INBRED RICE, AND SEED CERTIFICATION, AND FARM TECHNICAL EDUCATION AND GREEN HAVEN FARM
4/14/2023 7/28/2023 96Hrs TECHNICAL
MECHANIZATION SKILLS DEVELOPMENT AUTHORITY

SCHOOL LAC SESSION ON RPMS- PPST 9/3/2023 9/3/2023 8Hrs TECHNICAL DR. VICTORIA B. ROMAN MEMORIAL HIGH SCHOOL

SCHOOL INSET: 2024 INSET TITLED : "REVITALIZING EDUCATION: IN- SERVICE TRAINING
1/24/2023 1/30/2023 40Hrs TECHNICAL DR. VICTORIA B. ROMAN MEMORIAL HIGH SCHOOL
FOR ENGAGED AND EFFECTIVE TEACHERS"
TRAINING OF SENIOR HIGH SCHOOL TEACHERS ON UPLOADING OF LEARNERS SDO BATAAN -BULWAGAN NG MGA BAYANI AT
01/17-19/2024 02/6-8/2024 32Hrs TECHNICAL
ASSESSMENT AND CREATING CONTENT USING THE LEARNING MANAGEMENT SYSTEM BANAL

(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 N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE
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? ✘

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)

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
JONIL ABENIR PANTINGAN PILAR, BATAAN 9602115957 3.5 cm. X 4.5 cm
(passport size)

ROSEMARI NAGUIAT PANTINGAN PILAR, BATAAN 9810398331 With full and handwritten
name tag and signature over
printed name
AILEEN ALMENDRAS PANTINGAN PILAR, BATAAN 9087465161
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: PRC

ID/License/Passport No.: 1907418

Signature (Sign inside the box)

Date/Place of Issuance: 05/04/2022/ PAMPANGA

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