CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

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 PEROSIA
NAME EXTENSION (JR., SR)
FIRST NAME AILEEN

MIDDLE NAME PAGUNTALAN

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
1/20/1975 by by
birth naturalization
4. PLACE OF BIRTH BTAC.VIEJO,ILOILO If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS BANTUD

Widowed House/Block/Lot No. Street

Separate
LAPUZ NORTE
Other/s: d
Subdivision/Village Barangay
LAPUZ, ILOILO CITY ILOILO
7. HEIGHT (m) 1.55 m
City/Municipality Province
8. WEIGHT (kg) 64kg ZIP CODE 5000
18. PERMANENT ADDRESS BANTUD
9. BLOOD TYPE A
House/Block/Lot No. Street
LAPUZ NORTE
10. GSIS ID NO. 006-0045-8448-7
Subdivision/Village Barangay
LAPUZ, ILOILO CITY ILOILO
11. PAG-IBIG ID NO.
City/Municipality Province

12. PHILHEALTH NO. ZIP CODE 5000

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 948-106-849 20. MOBILE NO. 09260968256

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) aileen41perosia@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
PEROSIA
NAME EXTENSION (JR., SR)
FIRST NAME VINCENT AIVIE MARIE PEROSIA 10/23/2014

MIDDLE NAME CAMANDE

OCCUPATION FARMER

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME PAGUNTALAN

NAME EXTENSION (JR., SR)
FIRST NAME ALFREDO

MIDDLE NAME BANZALES

25. MOTHER'S MAIDEN NAME

SURNAME CANTO

FIRST NAME VILMA

MIDDLE NAME CONDEZ (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

VALEDICTO
ELEMENTARY SAN ANTONIO ELEMENTARY SCHOOL ELEMENTARY 1982 1988 Graduated 1988
RIAN

SECONDARY
VOCATIONAL / BTAC. VIEJO NATIONAL HIGH SCHOOL SECONDARY 1988 1992 Graduated 1992 N/A

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

TRADE
COURSE
COLLEGE UNIVERSITY OF ILOILO BSED 1994 2000 Graduated 2000 N/A

GRADUATE STUDIES GUIMARAS STATE COLLEGE MA FILIPINO 2016 2016 9 UNITS

(Continue on separate sheet if necessary)

SIGNATURE DATE 12/6/2018 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 EXAM. FOR TEACHERS 75.6 AUG.27,2000 ILOILO NATIONAL HIGH SCHOOL

(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

01/01/2019 to date TEACHER I JALANDONI MEM. NAT'L. HIGH SCH. P21,327.00 11-3
01/01/2018 12/31/2018 TEACHER I JALANDONI MEM. NAT'L. HIGH SCH. P20,698.00 11-2

01/01/2017 12/31/2017 TEACHER I JALANDONI MEM. NAT'L. HIGH SCH. P21,307.00 11-1

01/01/2016 12/31/20/16 TEACHER I JALANDONI MEM. NAT'L. HIGH SCH. P20,585.00 10-3

01/28/2014 12/31/2015 TEACHER I JALANDONI MEM. NAT'L. HIGH SCH. P19,887.00 10-2

06/01/2012 01/27/2014 TEACHER I JALANDONI MEM. NAT'L. HIGH SCH. P19,690.00 11-1
 (Continue on separate sheet if necessary)

SIGNATURE DATE 12/6/2018 CS FORM 212 (Revis

 LICENSE (if applicable)

NUMBER Date of
Validity

n separate sheet if necessary)

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

SERVICE

STATUS OF
APPOINTMENT

(Y/
N)
PERMANENT Y
PERMANENT Y

PERMANENT Y

PERMANENT Y

PERMANENT Y

PERMANENT Y
n 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 / NATURE OF WORK
From To

NA

(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

ISSC 2018 Coaches & Technical Officials Orientation on Different Sports Events 10/06/2018 10/06/2018 01/07/1900 Technical DepEd - Iloilo

ICSSC 2-18 Sports Solidarity & Forum of Coaches & Technical Officials 09/28/2018 09/29/2018 16 Technical DepEd - Iloilo City

School's INSET Training 10/25/2018 10/26/2018 16 Managerial JMNHS

Divisionl's INSET Training for Secondary Filipino Teachers 10/22/2018 10/24/2018 24 Managerial DepEd - Iloilo City

3-DAY REGIONAL TRAINING IN SPORTS COACHING 11/17/2016 11/19/2016 24 Technical Deped RO VI

(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 full)
(Write in full)

SEWING/DRESSMAKING JMNHS -TEDC

JMNHS PTA

(Continue on separate sheet if necessary)

SIGNATURE DATE 12/6/2018 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 ✘ 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? ________________________________
________________________________
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
the last 6 months
SALVADOR M. BESARES JALANDONI MEM. NAT'L. HIGH SCH. 336-18-09 3.5 cm. X 4.5 cm
(passport size)

ALEX S. PORRAS JALANDONI MEM. NAT'L. HIGH SCH. 336-18-09 With full and handwritten
name tag and signature over
printed name
LALICE JOY J ARQUINTILLO JALANDONI MEM. NAT'L. HIGH SCH.
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: GSIS UMID

ID/License/Passport No.: 006-0045-8448-7

Signature (Sign inside the box)
12/6/2018
Date/Place of Issuance: ILOILO CITY
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this 12/6/2018 , affiant exhibiting his/her validly issued government ID as indicated above.

RENATO T. BALLESTEROS, CESO VI

Person Administering Oath

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