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
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.

I. PERSONAL INFORMATION
2. SURNAME CAMPEÑA
FIRST NAME PHEBE
MIDDLE NAME SAAVEDRA
3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 02/26/91 ✘ Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH AGDANGAN, QUEZON If holder of dual citizenship, Pls. indicate coun
please indicate the details.
5. SEX Male ✘ Female

17. RESIDENTIAL ADDRESS San Vic

6 CIVIL STATUS ✘ Single Married
Widowed Separated House/Block/Lot No.
Other/s: Mag
Subdivision/Village Ba
7. HEIGHT (m) 1.56 Lopez Qu
City/Municipality P
8. WEIGHT (kg) 41 ZIP CODE 4316
18. PERMANENT ADDRESS
9. BLOOD TYPE A"Positive"
House/Block/Lot No.
Sitio Burol Brgy. Sila
10. GSIS ID NO. 02004414430
Subdivision/Village Ba

11. PAG-IBIG ID NO. 121107338534 Agdangan Qu

City/Municipality P
12. PHILHEALTH NO. 08-201066164-8 ZIP CODE 4304
13. SSS NO. N/A 19. TELEPHONE NO. N/A
14. TIN NO. 431-521-760 20. MOBILE NO. 09123565396
15. AGENCY EMPLOYEE NO. 4370753 21. E-MAIL ADDRESS (if any) phebe.campeña@deped.com
II. FAMILY BACKGROUN 3
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME ZHI CAMPEÑA
MIDDLE NAME ZHIA MARTHA CAMPEÑA
OCCUPATION
EMPLOYER/BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.

24. FATHER'S SURNAME CAMPEÑA

NAME EXTENSION (JR., SR)
FIRST NAME FROILAN
MIDDLE NAME AGUILAR
25. MOTHER'S MAIDEN NAME

SURNAME SAVEDRA
FIRST NAME LORNA
 MIDDLE NAME PAR (Continue on separate sheet if necessar

III. EDUCATIONAL BACKGROUND

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

AGDANGAN CENTRAL
ELEMENTARY PRIMARY 1997 2003 N/A
ELEMENTARY SCHOOL

VOCATIONAL
SECONDARY / AGDANGAN ACADEMY HIGH SCHOOL 2003 2007 N/A

N/A
TRADE POLYTECHNIC UNIVERSITY OF
COURSE BACHELOR IN BUSINESS
COLLEGE THE PHILIPPINES UNISAN 2008 2011 N/A
TEACHER EDUCATION
EXTENSION

GRADUATE STUDIES N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FO
L DATA SHEET
erience Sheet shall cause the filing of administrative/criminal case/s against the person

BEFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

Dual Citizenship

by naturalization
Pls. indicate country:

San Vicente Street

Street
Magsaysay
Barangay
Quezon
Province

Street
Brgy. Silangan Maligaya
Barangay
Quezon
Province

DATE OF BIRTH (mm/dd/yyyy)

07/19/2011
01/20/2016
 (Continue on separate sheet if necessary)

YEAR SCHOLARSHIP/
GRADUATED ACADEMIC HONORS
RECEIVED

2003 N/A

WITH
2007
HONORS

2011 N/A

eparate sheet if necessary)

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

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

BOARD FOR PROFESSIONAL TEACHER 76.00% 10/03/2013 LUCENA CITY 11955055

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

LOPEZ NATIONAL Php

07/13/2016 PRESENT SECONDARY SCHOOL TEACHER II
COMPREHENSIVE HIGH SCHOOL 23,387.00 11 PERMANENT

LOPEZ NATIONAL Php

3/6/2013 07/12/16 SECONDARY SCHOOL TEACHER I
COMPREHENSIVE HIGH SCHOOL 19,056.00 12 PERMANENT
 (Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017
 LICENSE (if applicable)

Date of
Validity

5/6/13

eparate sheet if necessary)

GOV'T
SERVICE

(Y/ N)

YES

YES
eparate 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

N/A N/A 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
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

Technical Lopez Nati

Gender Sensitivity Training 03/14/14 03/15/14 16 School
TRAINING OF GRADE 9 TEACHERS ON THE K-12 BASIC
Technical
EDUCATION CURRICULUM 05/12/2014 05/16/2014 40 DEP-ED Q
Technical Lopez Nati
In -Service Training for K-12 Program 05/26/14 05/30/14 40 School
5th Employees Congress with the theme "Hi Po.!: A Symposium on
Sexual Harassment and Everything in Between" Technical Calayan Ed
07/25/14 5
School Result -based Performance Management System (RPMS) Training Technical Lopez Nati
07/29/14 8 School
In - Service Training on Capacity Building for Secondary School Teachers
Technical Lopez Nati
of Cluster 12 10/20/14 10/23/14 32 School
TLE - TESDA Competency Assessment and Certification Preparatory
Technical
Acivity 10/30/14 8 DEP-ED Q
Division Seminar-Workshop/Thinkshop on Edukasyon sa Pagpapakatao
with the Theme: Integration of Values in the K to 12 Curriculum to Technical
Develop Nationalism Among Filipino Learners 11/24/2014 8 DEP-ED Q
Technical
GSP Basic and Age Level Courses 04/06/2015 04/08/2015 24 Girl Scout
Technical
GSP Outdoor Leadershop Course 04/14/2015 04/17/2015 32 Girl Scout
Technical
K-12 Mass Training for Grade 10 Teachers 05/10/2015 05/15/2015 48 DEP-ED Q
In - Service Training on Kto12 Basic Education Program (BEP) Updates
Technical Lopez Nati
for Lopez Secondary School Teachers and School Heads 05/27/15 05/29/15 24 School
6th Long Green Line with the Theme: Girl First! Imagine. Commit.Serv''.
Technical
Featuring "The Magic 3D" 08/8/15 8 Girl Scout
Technical
Occupational Safety and Health Course Appreciation 09/17/15 8 MSWD Lo
Division Seminar Workshop for Receiving Teacher Handling Children
Technical
with Specials Needs 10/26/15 10/28/15 24 DEP-ED Q
Technical Lopez Nati
Gender Sensitivity Training 10/29/15 10/30/15 16 School
 2015 International Mind Education Specialist Training with Cultural Education
Exchange Focusing on Leadership of Management Training and Technical Internation
Reformation of the Mind 12/4/15 12/6/15 24 Philippines

n separate sheet if necessary)

VIII. OTHER INFORMATION

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

COMPUTER LITERATE N/A

MS WORD /POWERPOINT
PRESENTATION/MICROSOFT EXCELL

(Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

N/A

eparate sheet if necessary)

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

CONDUCTED/ SPONSORED BY
(Write in full)

Lopez National Comprehensive High

School

DEP-ED QUEZON
Lopez National Comprehensive High
School
Calayan Educational Foundation,Inc.
Lucena, City
Lopez National Comprehensive High
School
Lopez National Comprehensive High
School

DEP-ED QUEZON

DEP-ED QUEZON

Girl Scout of the Philippines

Girl Scout of the Philippines

DEP-ED QUEZON
Lopez National Comprehensive High
School

Girl Scout of the Philippines

MSWD Lopez

DEP-ED QUEZON
Lopez National Comprehensive High
School
 Education Mind Institute and
International Youth Fellowship
Philippines

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

N/A

eparate sheet if necessary)

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:
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
MARILYN N. PERMEJO AGDANGAN,QUEZON 3.5 cm. X 4.5 cm
(passport size)

ELEANOR N. CASTRO AGDANGAN,QUEZON With full and handwritten

name tag and signature over
printed name
MONALISA P. NERONA AGDANGAN,QUEZON
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.: 11955055 Signature (Sign inside the box)
April 11, 2017
Date/Place of Issuance: FEB.26,2016 LUCENA CITY
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this 11th day of April, 2017 , 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