Вы находитесь на странице: 1из 16

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 aga
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

I. PERSONAL INFORMATION
2. SURNAME HINDAC
NAME EXTENSION (JR., SR)
FIRST NAME FATIMA

MIDDLE NAME OLLI


3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) Filipino Dual Citizenship
NOVEMBER03,1974 by birth by
4. PLACE OF BIRTH TINOC,IFUGAO If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male Female

Single Married 17. RESIDENTIAL ADDRESS


6 CIVIL STATUS
Widowed Separated House/Block/Lot No. PURO

Other/s:
Subdivision/Village MU
7. HEIGHT (m) 4'11"
DUPAX DEL NORTE NUEVA
8. WEIGHT (kg) 65 KLS ZIP CODE

18. PERMANENT ADDRESS


9. BLOOD TYPE O
House/Block/Lot No. PURO

10. GSIS ID NO. 006-009060825


Subdivision/Village NA

11. PAG-IBIG ID NO. 0301-10708006


DUPAX DEL NORTE NUEVA

12. PHILHEALTH NO. 19007116466 ZIP CODE 3706

13. SSS NO. 190071166 19. TELEPHONE NO. NONE

14. TIN NO. 02-188921-4 20. MOBILE NO. 09355171852

15. AGENCY EMPLOYEE NO. 14021 21. E-MAIL ADDRESS (if any) FATIMA O.HINDAC @ YAHOO.COM.

II. FAMILY BACKGROUND


22. SPOUSE'S SURNAME HINDAC 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) KENDRA KATE O.HINDAC
FIRST NAME WILSON
WILSON JOSHUA O. HINDAC
MIDDLE NAME DOMILIO
HARRYSON O.HINDAC
OCCUPATION NURSE 2

EMPLOYER/BUSINESS NAME DEPED SDO

BUSINESS ADDRESS DIVISION OFFICE,BAYOMBONG

TELEPHONE NO. 9756053548

24. FATHER'S SURNAME DECEASED


NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

25. MOTHER'S MAIDEN NAME BANTAG

SURNAME OLLI

FIRST NAME JUANITA

MIDDLE NAME BANIYAH (Continue on separate sheet if necessary

III. EDUCATIONAL BACKGROUND


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

ELEMENTARY KASIBU CENTRAL SCHOOL ELEMENTARY GRADUATE 1981 1986 4rth place

SECONDARY KASIBU NATIONALAGRICULTURAL SCHOOL HIGH SCHOOL GRADUATE 1986 1990 3rd place
VOCATIONAL /

N/A

TRADE
BACHELOR OF SCIENCE IN SECONDARY
COURSE
COLLEGE ST. MARY'S UNIVERSITY
EDUCATION
1991 1996 NONE

GRADUATE STUDIES NUEVA VIZCAYA STATE UNIVERSITY FINISHED ACAD IN ED.D 2000 6/26/1905 NONE

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM
DATA SHEET
erience Sheet shall cause the filing of administrative/criminal case/s against the person

EFORE ACCOMPLISHING THE PDS FORM.


(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Dual Citizenship

by naturalization

Pls. indicate country:

PUROK NARRA

MUNGUIA

NUEVA VIZCAYA

PUROK NARRA

NARRA

NUEVA VIZCAYA

NONE

09355171852

FATIMA O.HINDAC @ YAHOO.COM.

DATE OF BIRTH (mm/dd/yyyy)

11/13/2001

02/13/2004

MAY 12,2006

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

NONE

NONE
NONE

NONE
parate sheet if necessary)

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 ap
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

LICENSURE EXAMINATIONFOR TEACHERS


76,80% AUGUST 27,1997 BAGUIO CITY 0288428
(LET)

(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.
28. INCLUSIVE DATES SALARY/ JOB/ PAY
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

REGULAR
2004 PRESENT TEACHER III MUNGUIA NATIONAL HIGH SCHOOL 24,804.00
PERMANENT
REGULAR
1999 2004 TEACHER I MUNGUIA NATIONAL HIGH SCHOOL 18,549.00
PERMANENT
1999 2001 TEACHER I MUNGUIA NATIONAL HIGH SCHOOL 4000.00 PSEF

1997 1999 TEACHER I ST. JOSEPH'S SCHOOL 6550.00 CONTRACTUAL

1996 1997 TEACHER I MOUNTCARMEL HIGH SCHOOL 4000.00 CONTRACTUAL


(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 20
LICENSE (if applicable)

Date of
Validity

01/22/07

arate sheet if necessary)

GOV'T
SERVICE

(Y/
N)
YES

YES

YES

PRIVATE

PRIVATE
arate sheet if necessary)

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 /
From To

MUNGUIA DUPAX DEL NORTE 2004 PRESENT 3 HRS/WK PUROK SECRETARY

(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/
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To

Instructional Leaders' Development Training-Workshop 9/29/2016 9/30/2016 16 HOURS

INTERNATIONAL SEMINAR WORKSHOP,WRITESHOP ON ACTION RESEARCH 02,06,2015 05/17/2015 40 HOURS


DEPED NATIO

REGIONAL TRAININGOF GRADE10 FILIPINO TEACHERSOF K-12 ENHANCE


40 HOURS
BASICCURRICULUM 5/12,2015 5/17,2015 DEPED
REGIONAL TRAINING OF GRADE 8 EDUKAYON SA PAGPAPAKATAO OF THE K-12
5/ 26,2012 5/21/2015 40 HOURS
ENHANCE BASICCURRICULUM DEPED
(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


MEMBERS
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

ENCODING

GARDENING

(Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

PUROK SECRETARY

eparate sheet if necessary)


ROGRAMS ATTENDED
five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

DEPED NATION AL CAPITAL REGION,PRC ACREDITATION

DEPED REGIONAL OFFICE

DEPED REGIONAL OFFICE


eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

eparate sheet if necessary)

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
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 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 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 wi
the last 6 month
LETIICIA B.ORPIA MUNGUIA ,DUPAX DEL NORTE 9155345240 3.5 cm. X 4.5 cm
(passport size)

AGNES D. ILARDE MUNGUIA ,NATIONAL HIGH SCHOOL 9358120920 With full and handw
name tag and signatu
DUPAX DEL NORTE NATIONAL HIGH printed name
GUILBERT R. ORCALES SCHOOL
977833990
Computer generat
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied pict
is not acceptabl
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: 0288428

ID/License/Passport No.:
006-00960825 Signature (Sign inside the box)

Date/Place of Issuance: 11/0301999


Date Accomplished Right Thumbmar

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated a

JULIUS CAESAR G. DOMINGO


ACCOUNTANT III
Person Administering Oath

CS FORM 212 (Revised


If YES, give details:
________________________________

If YES, give details:


________________________________
________________________________

If YES, give details:


________________________________
________________________________

If YES, give details:


________________________________
________________________________

If YES, give details:


________________________________
________________________________
NO

NO

NO
If YES, give details (country):

NO

NO

NO

ID picture taken within


the last 6 months
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten


name tag and signature over
printed name

Computer generated
or photocopied picture
is not acceptable

PHOTO

Right Thumbmark

, affiant exhibiting his/her validly issued government ID as indicated above.


CS FORM 212 (Revised 2017), Page 4 of 4