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 TABUADA
NAME EXTENSION (JR., SR) N/A
FIRST NAME JOHN REY

MIDDLE NAME FLORES

3. DATE OF BIRTH
(mm/dd/yyyy) 8/13/1990 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH SAN CARLOS CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS BLCK 4, LOT 8 PHASE 4
Widowed Separated House/Block/Lot No. Street
FATIMA VILLAGE RIZAL
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 1.67 SAN CARLOS CITY NEGROS OCCIDENTAL
City/Municipality Province
8. WEIGHT (kg) 64 ZIP CODE

9. BLOOD TYPE A+
18. PERMANENT ADDRESS BLCK 4, LOT 8 PHASE 4
House/Block/Lot No. Street

10. GSIS ID NO. ON PROCESS FATIMA VILLAGE RIZAL

Subdivision/Village Barangay

11. PAG-IBIG ID NO.

SAN CARLOS CITY NEGROS OCCIDENTAL
City/Municipality Province

12. PHILHEALTH NO. ZIP CODE 6127

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

14. TIN NO. ON PROCESS 20. MOBILE NO. 09478021564

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

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME TABUADA

NAME EXTENSION (JR., SR)
FIRST NAME CARLOS

MIDDLE NAME BARAN

25. MOTHER'S MAIDEN NAME

SURNAME FLORES

FIRST NAME CECILIA

MIDDLE NAME BACASMAS (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
GRADUATE
HONORS
(Write in full) D
full) (if not graduated) RECEIVED
From To

SAN CARLOS MILLING COM. INC.

ELEMENTARY PRIMARY EDUCATION 1997 2003 GRADUATED 2003 N/A
ELEMENTARY SCHOOL
VOCATIONAL
SECONDARY / CENTRAL NEGROS COLLEGE HIGH SCHOOL 2003 2008 GRADUATED 2008 N/A
ST. JOSEPH COMPUTER LEARNING COMPUTER HARDWARE & SERVICES
2010 2010 COMPUTER 2010 N/A
CENTER NCII
TRADE
COURSE
AB ENGLISH 2011 2011 25 UNITS N/A N/A
CENTRAL NEGROS COLLEGE
COLLEGE BEED 2011 2012 47 UNITS N/A N/A
BSED -
TAÑON COLLEGE 2012 2016 GRADUATED 2016 N/A
MAPEH

GRADUATE STUDIES N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE March 23, 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

LICENSE PROFESSIONAL TEACHER 76.40 9/1/2017 CEBU CITY 1628501 8/3/2024

(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) STATUS OF
(Write in full/Do not (Write in MONTHLY SALARY applicable)& STEP
APPOINTMENT
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)
COLEGIO DE SANTA RITA DE SAN Php CONTRACTUA
6/1/2017 3/15/2020 TEACHER N/A N
CARLOS INC. 10,000.00 L

(Continue on separate sheet if necessary)

SIGNATURE DATE MARCH 23, 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
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) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To
LGU SAN CARLOS / CEMO SAN CARLOS CITY
WILDLIFE PHOTOGRAPHY WORKSHOP 2019 11/23/2019 11/24/2019 16 HRS TECHNICAL
NEGROS OCCIDENTAL

INSET 2019 05/10/2019 05/12/2019 24 HRS TECHNICAL PRIVATE EDUCATION ASSISTANCE COMMITTEE

INSET 2018 4/30/2018 5/2/2018 24 HRS TECHNICAL PRIVATE EDUCATION ASSISTANCE COMMITTEE

INSET FOR PRIVATE SCHOOL 2017 7/29/2017 11/29/2017 8 HRS TECHNICAL ST. AGUSTINE PUBLICATIONS, INC.

(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)

VIDEO EDITING N/A N/A

PHOTOGRAPHY N/A N/A

GRAPHIC DESIGN N/A N/A

MUSIC EDITING N/A N/A

DRONE PILOT N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE MARCH 23, 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? 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 END OF CONTRACT
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
SAN CARLOS CITY NEGROS the last 6 months
DR. EVANGELENE ABANA - FROYLAN 9162683205 4.5 cm. X 3.5 cm
OCCIDENTAL (passport size)
SAN CARLOS CITY NEGROS
MRS. MARILOU A. MACATUAL 9060584409
OCCIDENTAL Computer generated
or photocopied picture
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
ID/License/Passport No.: 1628501 Signature (Sign inside the box)
MARCH 23, 2023
Date/Place of Issuance: 3/27/2018 / CEBU 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