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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 ag
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 C

I. PERSONAL INFORMATION
2. SURNAME GARCIA
NAME EXTENSION (JR., SR)
FIRST NAME MA. GELENE

MIDDLE NAME ULITIN


3. DATE OF BIRTH
(mm/dd/yyyy) 10/28/1996 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by naturaliza
4. PLACE OF BIRTH TANAY, RIZAL If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

✘ Single Married 17. RESIDENTIAL ADDRESS 018 PUROK 1


6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
GULOD
Other/s:
Subdivision/Village Barangay
LAUREL BATANGAS
7. HEIGHT (m) 1.524
City/Municipality Province
8. WEIGHT (kg) 68 ZIP CODE 4221
18. PERMANENT ADDRESS 018 PUROK 1
9. BLOOD TYPE "A"
House/Block/Lot No. Street
GULOD
10. GSIS ID NO.
Subdivision/Village Barangay
LAUREL
11. PAG-IBIG ID NO. 121204703089
City/Municipality Province
12. PHILHEALTH NO. 090254427747 ZIP CODE 4221

13. SSS NO. 0439384915 19. TELEPHONE NO. N/A

14. TIN NO. 339072173000 20. MOBILE NO. 09070991562

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) ma_gelene_garcia@dlsl.edu.ph / adamgelian28@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) GELIAN XIANELLE G. ARGEL
FIRST NAME N/A

MIDDLE NAME N/A ADAM CHRISTMIEL GARCIA

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A


24. FATHER'S SURNAME GARCIA
NAME EXTENSION (JR., SR)
FIRST NAME GERARDO

MIDDLE NAME BASCO

25. MOTHER'S MAIDEN NAME

SURNAME ULITIN

FIRST NAME ZENAIDA

MIDDLE NAME SERRANO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND


HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE LEVEL/
26. PERIOD OF ATTENDANCE UNITS
LEVEL (Write in full) EARNED
(Write in full) (if not
From To
graduated)
ELEMENTARY SERVITE CATHOLIC SCHOOL ELEMENTARY 6/23/2001 4/1/2009
VOCATIONAL / LA CONSOLACION COLLEGE
SECONDARY
TANAUAN
HIGH SCHOOL 6/6/2009 4/28/2013

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


BACHELOR OF SECONDARY EDUCATION
COLLEGE TRADE DE LA SALLE UNIVERSITY LIPA 10/15/2014 6/6/2019
COURSE MAJOR IN ENGLISH

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE January 3, 2020

CS FORM 212 (Revised 201


ve/criminal case/s against the

(Do not fill up. For CSC use only)

XTENSION (JR., SR)

tizenship
birth by naturalization

s. indicate country:

PUROK 1
Street
GULOD
Barangay
BATANGAS
Province

PUROK 1
Street
GULOD
Barangay
BATANGAS
Province

gelian28@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

8/28/2013

8/8/2015
if necessary)

SCHOLARSHIP/
YEAR ACADEMIC
GRADUATED HONORS
RECEIVED

SALUTATO
2009
RIAN
WITH
2013 HONORS
N/A N/A

2019 CHED &


MANDANAS
SCHOLARSHI
P

January 3, 2020

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

LICENSURE EXAMINATION FOR TEACHERS 80.0 9/29/2019 LUCENA CITY 1827882 10/28/2023

(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
SERVICE
28. INCLUSIVE DATES SALARY/ JOB/
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY PAY GRADE (if STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To (Y/
N)
8/8/2019 2/3/2020 CUSTOMER SERVICE RERESENTATIVE THE RESULT COMPANIES P 14000 TEMPORARY N

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (Write in
full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

N/A N/A

(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
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) From To Technical/etc)

TEACH FOR THE PHILIPPINES' ORIENTATION- TEACH FOR THE PHILIPPINES (MS. JOYCE
3/28/2019 3/28/2019 8 HRS SUPERVISORY
SEMINAR ANGELI DONAIRE)
PREPARING TEACHERS TOWARDS RESPONSIBLE
3/7/2019 3/7/2019 8 HRS SUPERVISORY MS. PATRICE MANGULABNAN
GLOBAL CITIZENSHIP EDUCATION

21ST CENTURY ASSESSMENT PRACTICES 1/24/2019 1/24/2019 8 HRS SUPERVISORY DR. JAY MCTIGHE

PHILIPPINE ASSOCIATION FOR TEACHERS


CALABARZON PRE-SERVICE TEACHERS SEMINAR 9/27/2018 9/27/2018 8 HRS SUPERVISORY
EDUCATORS (PAFTE)

DISASTER PREPAREDNESS SEMINAR 4/6/2018 4/6/2018 4 HRS TECHNICAL DLSL EDUCATOR'S CIRCLE

THEMATIC/INTEGRATED APPROACHES TO TEACHING DLSL EDUCATORS' CIRCLE (SPEAKER: MR.


4/5/2018 4/5/2018 8 HRS SUPERVISORY
(EDUCATORS' CONGRESS 2018) GLENFORD M. PROSPERO, PH.D)

CHILD PROTECTION LAW 5/8/2017 5/8/2017 4 HRS TECHNICAL DLSL EDUCATORS' CIRCLE

EDUCATORS' CONGRESS 2017 3/11/2017 3/11/2017 8 HRS SUPERVISORY DLSL EDUCATORS' CIRCLE

BASIC FIRST AID SEMINAR FOR LASALLIAN


3/4/2017 3/4/2017 4 HRS TECHNICAL DLSL EDUCATORS' CIRCLE
EDUCATORS

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 33.
(Write in full) (Write
in full)

(Continue on separate sheet if necessary)

SIGNATURE DATE
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 theof bureau or office or to the person who has immediate supervision over you in the
chief
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 by any court or tribunal?
YES ✘ NO
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 If YES, give details:
phased out (abolition) in the public or private sector? ________________________________
RESIGNATION DUE TO UNAVOIDABLE REASONS
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year
YES ✘ NO
(except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
the last 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
a.
items:
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
DE LA SALLE UNIVERSITY the last 6 months
JOY TALENS, PH.D LIPA
9177832846 3.5 cm. X 4.5 cm
(passport size)
DE LA SALLE UNIVERSITY
MARIA THERESA KALAW, PH.D LIPA
9555805385 With full and handwritten
name tag and signature over
PRINCIPAL III - GULOD printed name
GINALYN U. MACARAIG, PH.D ELEMENTARY SCHOOL
9399161077
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct or photocopied picture
is not acceptable
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 PHOTO
filing of 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: UMID

ID/License/Passport No.: 0111-8101630-7


Signature (Sign inside the box)

Date/Place of Issuance: LEMERY, BATANGAS


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

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