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 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 BALASABAS
NAME EXTENSION (JR., SR)
FIRST NAME EUGENIO

MIDDLE NAME ESTRELLA

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 5/10/1995 ✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
MAGANAY, BUUG, ZAMBOANGA
4. PLACE OF BIRTH If holder of dual citizenship, Pls. indicate country:
SIBUGAY
please indicate the details.
5. SEX ✘ Male Female

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

Other/s:
Subdivision/Village Barangay

7. HEIGHT (m) 1. 65m

City/Municipality Province
8. WEIGHT (kg) 55kg ZIP CODE

18. PERMANENT ADDRESS PUROK 2

9. BLOOD TYPE A+
House/Block/Lot No. Street

10. GSIS ID NO. POBLACION

Subdivision/Village Barangay
BUUG ZAMBOANGA SIBUGAY
11. PAG-IBIG ID NO. 1211-8793-1864
City/Municipality Province

12. PHILHEALTH NO. 140502235334 ZIP CODE 7009

13. SSS NO. 10 - 1224593 - 3 19. TELEPHONE NO.

14. TIN NO. 336 - 175 - 923 20. MOBILE NO. 0935 281 7816
15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) eugeniobalasabas19@gmail.com
II. FAMILY BACKGROUND
DATE OF BIRTH
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all)
(mm/dd/yyyy)
FIRST NAME NAME EXTENSION (JR., SR)

MIDDLE NAME
OCCUPATION
EMPLOYER/BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.

24. FATHER'S SURNAME BALASABAS

FIRST NAME CARLOS SR.

MIDDLE NAME SOLIS

25. MOTHER'S MAIDEN NAME

SURNAME ESTRELLA

FIRST NAME ALICE

MIDDLE NAME CHAVEZ (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY BUUG PILOT CENTRAL SCHOOL 2008

SECONDARY BUUG NATIONAL HIGH SCHOOL 2012

VOCATIONAL /
WESTERN INSTITUE OF TECH INC.-IMELDA
TRADE COURSE
COLLEGE MINDANAO STATE UNIVERSITY - BUUG CAMPUS BSED - MATHEMATICS 2016
GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE
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

LET BOARD PASSER 78.40 PAGADIAN CITY 1536643 5/10/2020

(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
28. INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
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
(Y/ N)
WESTERN MINDANAO INSTITUTE OF
6/1/2016 4/30/2018 TEACHER 6000.00 NONE CONTRACTUAL N
BUUG INC.
 (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
INCLUSIVE DATES
29. NAME & ADDRESS OF ORGANIZATION NUMBER OF
(Write in full) HOURS POSITION / NATURE OF WORK
(mm/dd/yyyy)
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 NUMBER OF ( Managerial/ CONDUCTED/ SPONSORED BY
(Write in full) HOURS Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To
NATIONAL COUNCIL FOR CHILDREN'S
UNDERSTANDING AND UTILIZING MEDIA IN TEACHING (UUMT) 8/7/2018 8/9/2018 24 TECHNICAL TELEVISION
ORIENTATION OF NEWLY-HIRED TEACHERS ON TEACHERS INDUCTION DEPED- REGIONAL OFFICE IX - ZAMBOANGA
8/17/2018 8/17/2018 TECHNICAL
PROGRAM PENINSULA

DIVISION ORIENTATION ON TEACHERS INDUCTION PROGRAM 11/21/2018 11/21/2018 TECHNICAL DEPED - DIVISION OF ZAMBOANGA SIBUGAY

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full) (Write in
full)
PLAYING BALLGAMES (Soccer, Basketball,
Badminton and Baseball)
ELECTRICAL WIRING INSTALLATION

(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 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? ________________________________
________________________________
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: SUBANEN
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 CELL NO.

ID picture taken within
the last 6 months
GINA D. TORRED BUUG ZAMBOANGA SIBUGAY 3.5 cm. X 4.5 cm
(passport size)

PANFILO A. CASTOR BUUG ZAMBOANGA SIBUGAY With full and handwritten

name tag and signature over
printed name

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/License/Passport No.: 1536643 Signature (Sign inside the box)

Date/Place of Issuance: PAGADIAN/ 06/01/2017 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