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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 CALUNSAG
NAME EXTENSION (JR., SR
FIRST NAME EL NIÑO

MIDDLE NAME BUTCHE


3. DATE OF BIRTH
(mm/dd/yyyy) 11/8/1993 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by

4. PLACE OF BIRTH SAN CARLOS CITY If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS SITIO
Widowed Separated House/Block/Lot No. S

Other/s: BULU
Subdivision/Village Ba
7. HEIGHT (m) 1.65m SAN CARLOS CITY NEGROS O
City/Municipality Pr
8. WEIGHT (kg) 56kg ZIP CODE 6127

9. BLOOD TYPE O+
18. PERMANENT ADDRESS SITIO
House/Block/Lot No. S

10. GSIS ID NO. NONE BULU


Subdivision/Village Ba

11. PAG-IBIG ID NO. 1210-8224-4105 SAN CARLOS CITY NEGROS OCC


City/Municipality Pr

12. PHILHEALTH NO. 11-050607387-1 ZIP CODE 6127

13. SSS NO. 07-2826848-3 19. TELEPHONE NO. NONE

14. TIN NO. 735 529 722 20. MOBILE NO. 09569170978
15. AGENCY EMPLOYEE NO. NONE 21. E-MAIL ADDRESS (if any) darwin11080993@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 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 CALUNSAG


NAME EXTENSION (JR., SR)
FIRST NAME ANTONIO
MIDDLE NAME BARROCA

25. MOTHER'S MAIDEN NAME

SURNAME BUTCHE

FIRST NAME SUSANA

MIDDLE NAME MALUNAR (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 TROZO ELEMENTARY SCHOOL PRIMARY EDUCATION 1999 2005 GRADUATED

DON CARLOS LEDESMA NATIONAL HIGH


SECONDARY /
VOCATIONAL SCHOOL
HIGH SCHOOL 2005 2009 GRADUATED

NONE

TRADE
BACHELOR OF SCIENCE IN INFORMATION
COURSE
COLLEGE CENTRAL PHILIPPINES STATE UNIVERSITY
TECHNOLOGY
2014 2018 GRADUATED

GRADUATE STUDIES NONE

(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)

Dual Citizenship

by naturalization

Pls. indicate country:

SITIO TROZO
Street
BULUANGAN
Barangay
NEGROS OCCIDENTAL
Province
6127

SITIO TROZO
Street
BULUANGAN
Barangay
NEGROS OCCIDENTAL
Province

NONE

09569170978

darwin11080993@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

N/A
(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2005 NONE

2009 NONE

CUM
2018
LAUDE

parate sheet if necessary)

June 25, 2019


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

Presidential Decree No. 907 CUMLAUDE JULY 31, 2018 CSC RO VI, ILOILO CITY

(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

DEPED DIVISION OF SAN CARLOS


06/18/2018 PRESENT OFFICE AIDE 5600.00
CITY
11/1/2015 01/30/2016 ENUMERATOR DSWD 4500.00

5/1/2015 07/30/2015 ENUMERATOR DSWD 4500.00

02/15/2013 06/25/2013 HOUSE KEEPER GAISANO CAPITAL SAN CARLOS 6160.00


(Continue on separate sheet if necessary)

SIGNATURE DATE June 25, 2019


CS FORM 212
LICENSE (if applicable)

NUMBER Date of
Validity
10010618117 APRIL
9 13,2018

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)
JOB ORDER YES

CONTRACTUAL YES

CONTRACTUAL YES

CONTRACTUAL NO
ue on separate sheet if necessary)

June 25, 2019


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

NONE

(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
CAPSTONE PROJECT, WEB DEVELOPMENT, ARDUINO, IMAGE CENTRAL P
12/05/2017 12/6/2017 18.0
PROCESSING AND ANDROID APPLICATION DEVELOPMENT UNIVERSIT
WEB DEVELOPMENT, MULTIMEDIA DEVELOPMENT, ARDUINO AND CENTRAL P
12/08/2016 12/9/2016 18.0
ANDROID APPLICATION UNIVERSIT
MICRO-ENTREPENEURSHIP IN CREATIVE ALTERNATIVE FOR KAUS
07/16/2012 09/26/2012 200.0
SUSTAINABLE HEALTH (CASH)
SAIN
SAINT JOSEPH COMPUTER LEARNING SYSTEM 10/26/2011 4/9/2012 356.0
L
ALTERNATIVE LEARNING SYSTEM (SOFTWARE AND HARDWARE
01/04/2010 06/26/2010 492.0 DEPED ALT
OPERATION)
ALTERNATIVE LEARNING SYSTEM (SOFTWARE OPERATION) 07/01/2009 12/23/2009 492.0 DEPED ALT
(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


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

PROGRAMMING
NONE
(PHP,HTML,CSS,JAVASCRIPT)
COMPUTER TROUBLESHOOT

COMPUTER NETWORKING

ENCODING

(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)

CENTRAL PHILIPPINES STATE


UNIVERSITY
CENTRAL PHILIPPINES STATE
UNIVERSITY
KAUSWAGAN UNITED PARENT
ASSOCIATION INC.
SAINT JOSEPH COMPUTER
LEARNING SYSTEM
DEPED ALTERNATIVE LEARNING SYSTEM

DEPED ALTERNATIVE LEARNING SYSTEM


eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

NONE

eparate sheet if necessary)

June 25, 2019


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? ________________________________
Finished contract
________________________________
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
YLAGAN STREET BRGY. V, SAN the last 6 months
ARNOLD MAHINAY CARLOS CITY, NEG. OCC
9159325616 3.5 cm. X 4.5 cm
(passport size)
6TH STREET ST. VINCENT SUBDIVISION,
INGRID E. CATALAN SAN CARLOS CITY, NEG. OCC.
9083062393 With full and handwritten
name tag and signature over
printed name
SAN JULIO SUBD. NANGKA ST. BRGY. II,
MA. ALYZA M. RODRIGUEZ SAN CARLOS CITY, NEG. OCC.
9171189909
Computer generated
42. or photocopied picture
I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and 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: PHILHEALTH

ID/License/Passport No.: 11-050607387


Signature (Sign inside the box)
June 25, 2019
Date/Place of Issuance: 06/25/2013 SAN CARLOS 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