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 ag
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 CORTAN
NAME EXTENSION (JR., SR
FIRST NAME RESTITUTO

MIDDLE NAME BERCES

3. DATE OF BIRTH
(mm/dd/yyyy) 7/15/1995 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH NATO, SAGÑAY, CAMARINES SUR If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX ✘ Male Female

✘ Single Married 17. RESIDENTIAL ADDRESS 85

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. S
UPPER TIBAGAN GEN. T
Other/s:
Subdivision/Village Ba
VALENZUELA
7. HEIGHT (m) 173
City/Municipality Pr
8. WEIGHT (kg) 60 ZIP CODE 1442

18. PERMANENT ADDRESS 85

9. BLOOD TYPE N/A
House/Block/Lot No. S
UPPER TIBAGAN GEN. T
10. GSIS ID NO. N/A
Subdivision/Village Ba
VALENZUELA
11. PAG-IBIG ID NO. 1211-6918-2956
City/Municipality Pr

12. PHILHEALTH NO. 0202-6692-8190 ZIP CODE 1442

13. SSS NO. 0111-6482532-4 19. TELEPHONE NO. N/A

14. TIN NO. 330749695 20. MOBILE NO. 09051954900

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) ginoongcortan@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME CORTAN

NAME EXTENSION (JR., SR)
FIRST NAME RESTITUTO

MIDDLE NAME CAM

25. MOTHER'S MAIDEN NAME MARIANA CHAVEZ BERCES

SURNAME CORTAN

FIRST NAME MARIANA

MIDDLE NAME BERCES (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 GEN. T. DE LEON ELEMENTARY SCHOOL N/A 2002 2008

SECONDARY GEN. T. DE LEON NATIONAL HIGH SCHOOL N/A 2008 2012

VOCATIONAL /

SABAS SKILLS DEVELOPMENT AND

ASSESSMENT CENTER INC.
BREAD AND PASTRY PRODUCTION, NCII 2017 2017

TRADE
COURSE BACHELOR OF SECONDARY EDUCATION
COLLEGE PAMANTASAN NG LUNGSOD NG VALENZUELA
MAJOR IN FILIPINO
2012 2016

GRADUATE STUDIES N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE June

CS FORM
L 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) JR.

Dual Citizenship

by naturalization

Pls. indicate country:

Street
GEN. T. DE LEON
Barangay
NCR
Province
1442

Street
GEN. T. DE LEON
Barangay
NCR
Province

N/A

09051954900

ginoongcortan@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2008 N/A

2012 N/A
 2017 N/A

Win ang
2016 Edukasyon

parate sheet if necessary)

June 21, 2018

CS FORM 212 (Revised 2017), Page 1 of 4

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

LICENSURE EXAMINATION FOR TEACHERS 81.8 3/26/2017 HOLY TRINITY ACADEMY

(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
(Write in full/Do not (Write in SALARY
applicable)& STEP
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To

6/13/2016 4/5/2018 HIGH SCHOOL TEACHER DEPARTMENT OF EDUCATION 10000.00

 (Continue on separate sheet if necessary)

SIGNATURE DATE 06/21/2018

CS FORM 212
 LICENSE (if applicable)

NUMBER Date of
Validity

1537176 7/15/2020

ue on separate sheet if necessary)

n of duties should be indicated in the attached Work Experience sheet. GOV'T

SERVICE

STATUS OF
APPOINTMENT

(Y/
N)
Contractual N
ue on separate 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

(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

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

Speedsolver (Rubikscube) Rubiks Magic National Record Holder in 2010 W

Road Cyclist Rubiks with Feet 2nd National Record Holder in 2010 Phi

Guitarist Open

Bassist

Song Leader

(Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

eparate sheet if necessary)

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

CONDUCTED/ SPONSORED BY
(Write in full)

eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

World Cube Association

 Philippine Cuber Association

Open Heaven Christian Church

eparate sheet if necessary)

06/21/2018
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 If YES, give details:
out (abolition) in the public or private sector? St. Paul Christian School in 2018
________________________________
________________________________
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
24 Tade St., Karuhatan, Valenzuela the last 6 months
St. Paul Christian School City
285-0619 3.5 cm. X 4.5 cm
(passport size)
None/
Mrs. Cherry Anne Conception – Castillo Parada, Valenzuela City
09159357526 With full and handwritten
name tag and signature over
None/ printed name
Mr. Roderick Alo Dalandanan, Valenzuela City
09228092107 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

ID/License/Passport No.: 1537176

Signature (Sign inside the box)
06/21/2018
Date/Place of Issuance: 06/02/2017
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this 21st of June 2018 , affiant exhibiting his/her validly issued government ID as indicated above.

Person Administering Oath

CS FORM 212 (Revised 2017), Page 4 o

 If YES, give details (country):

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

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