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 MILO
NA
FIRST NAME ANNA MARIE

MIDDLE NAME ZAMBALES

3. DATE OF BIRTH
(mm/dd/yyyy) 3/31/1992 16. CITIZENSHIP ✘ Filipino Dual Citizenship
✘ by birth by
4. PLACE OF BIRTH MARIKINA CITY If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male ✘ Female

✘ Single Married 17. RESIDENTIAL ADDRESS BLK 5 LOT 1 A

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. S
KAPAYAPAAN VILLAGE BRGY C
Other/s:
Subdivision/Village Ba
CALAMBA CITY LA
7. HEIGHT (m) 1.54M
City/Municipality Pr
8. WEIGHT (kg) 57KGS ZIP CODE 4027

18. PERMANENT ADDRESS BLK 5 LOT 1 A

9. BLOOD TYPE AB+
House/Block/Lot No. S
KAPAYAPAAN VILLAGE BRGY C
10. GSIS ID NO. 200477370
Subdivision/Village Ba
CALAMBA CITY LAG
11. PAG-IBIG ID NO. 121090531406
City/Municipality Pr

12. PHILHEALTH NO. 080513289964 ZIP CODE 4027

13. SSS NO. NA 19. TELEPHONE NO. NA

14. TIN NO. 441362423 20. MOBILE NO. 09502686228

15. AGENCY EMPLOYEE NO. 5490427 21. E-MAIL ADDRESS (if any) CAVEGANGLAHI@YAHOO.C
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME NA 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME NA ANNE STELLA MILO

MIDDLE NAME NA

OCCUPATION NA

EMPLOYER/BUSINESS NAME NA

BUSINESS ADDRESS NA

TELEPHONE NO. NA

24. FATHER'S SURNAME MILO

NAME EXTENSION (JR., SR)
FIRST NAME MARITO

MIDDLE NAME DIEZ

25. MOTHER'S MAIDEN NAME ANALEAH A. ZAMBALES

SURNAME ZAMBALES

FIRST NAME ANALEAH

MIDDLE NAME ADVINCULA (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 SAN RAMON ELEMENTARY SCHOOL ELEMENTARY 2003 2005 GRADUATE

SECONDARY LITTLE JESUS LEARNING CENTER HIGH SCHOOL 2005 2009 GRADUATE
VOCATIONAL /

CLASSNOVATION SKILLS LEARNING CENTER COMPUTER LITERACY 2015 2015 GRADUATE

TRADE
BACHELOR OF SECONDARY EDUCATION
COURSE
COLLEGE CITY COLLEGE OF CALAMBA
MAJOR IN MATHEMATICS
2009 2013 GRADUATE

MASTER OF ARTS IN ADMINISTRATION AND

GRADUATE STUDIES LAGUNA COLLEGE OF BUSINESS AND ARTS
SUPERVISION
2016 2017 18 UNITS
(Continue on separate sheet if necessary)

SIGNATURE DATE March

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)

NA

Dual Citizenship

by naturalization

Pls. indicate country:

ASIA I
Street
BRGY CANLUBANG
Barangay
LAGUNA
Province
4027

ASIA I
Street
BRGY CANLUBANG
Barangay
LAGUNA
Province

4027

NA

09502686228

CAVEGANGLAHI@YAHOO.COM

DATE OF BIRTH (mm/dd/yyyy)

4/15/2018

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2005

2009
 2015

SERVICE
2013
AWARDEE

-
parate sheet if necessary)

March 20, 2019

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 ap
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

LICENSURE EXAMINATION FOR TEACHERS 80.4 9/1/2013 LUCENA CITY 1245590

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

2/6/2019 3/19/2019 TEACHER I DEPED - CALAMBA P20,709 11-1 SUBSTITUTE

8/27/2015 12/5/2017 TEACHER I DEPED - CALAMBA P19,601 11-1 PERMANENT

CONTRACTU
6/1/2013 3/31/2015 FACULTY CALAMBA INSTITUTE - MAIN P11800 NA
AL
 (Continue on separate sheet if necessary)

SIGNATURE DATE 3/20/2019

CS FORM 212 (Revised 20

 LICENSE (if applicable)

Date of
Validity

3/31/2019

arate sheet if necessary)

GOV'T
SERVICE

(Y/
N)
Y

N
arate sheet if necessary)

3/20/2019

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

KAPAYAPAAN YOUTH ORGANIZATON (BRGY CANLUBANG CALAMBA) 4/1/2012 12/1/2014 NA SECRETARY

(Continue on separate sheet if necessary)

(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

DIVISION FESTIVAL OF DEMONSTRATION TEACHING 10/23/2017 10/27/2017 40.0 TECHNICAL DEP

DIVISION FESTIVAL OF TALENTS IN MATHEMATICS 2017 9/21/2017 9/21/2017 8.0 TECHNICAL DEP

ORIENTATION SEMINAR ON SCHOOL- BASED FEEDING, WASH IN SCHOOLS,

8/29/2017 8/29/2017 8.0 TECHNICAL DEP
CANTEEN AND FOOD SAFETY

DIVISION RE-TRAINING ON NUTRITIONAL ASSESSMENT 6/2/2017 6/2/2017 8.0 TECHNICAL DEP

INSERVICE TRAINING OF TEACHERS FOR KINDERGARTEN TO GRADE 10 5/8/2017 5/9/2017 16.0 TECHNICAL DEP

SCHOOL - BASED INSET FOR TEACHERS ON K12 CURRICULUM 5/22/2017 5/26/2017 40.0 TECHNICAL

1ST DEVELOPMENTAL TRAINING IN MATHEMATICS 2/4/2017 2/4/2017 8.0 TECHNICAL DEP

SEMINAR WORKSHOP IN TEACHING MUSIC 10/26/2016 10/28/2016 24.0 TECHNICAL DEP

DIVISION INSERVICE TRAINING FOR MATHEMATICS TEACHERS 10/24/2016 10/26/2016 24.0 TECHNICAL DEP

DIVISION TEACHER INDUCTION PROGRAM FOR NEWLY HIRED TEACHERS 6/8/2016 6/10/2016 24.0 TECHNICAL DEP

DIVISION ON COACHING AND OFFICIATING FOR ATHLETICS, SWIMMING, TABLE

11/13/2015 11/14/2015 8.0 TECHNICAL DEP
TENNIS, AND ARNIS

SCHOOL - BASED INSET FOR TEACHERS 10/26/2015 10/30/2015 40.0 TECHNICAL

ESP: PANANAGUTAN AT TUNGKULIN PARA SA KABATAAN NGAYON AT SA

9/18/2015 9/18/2015 8.0 TECHNICAL DEP
KINABUKASAN

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

SURFING ON THE INTERNET UNESCO - LEAD SERVICE AWARDEE

 SINGING KAPAYAP

PLAYING MUSICAL INSTRUMENTS

LAY-OUTING LOGO USING COREL DRAW

COMPUTER LITERATE

BASKETBALL

(Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

SECRETARY

eparate sheet if necessary)

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

CONDUCTED/ SPONSORED BY
(Write in full)

DEPED- DIVISION OF CALAMBA

DEPED- DIVISION OF CALAMBA

DEPED- DIVISION OF CALAMBA

DEPED- DIVISION OF CALAMBA

DEPED- DIVISION OF CALAMBA

MABATO NHS

DEPED- DIVISION OF CALAMBA

DEPED- DIVISION OF CALAMBA

DEPED- DIVISION OF CALAMBA

DEPED- DIVISION OF CALAMBA

DEPED- DIVISION OF CALAMBA

MABATO NHS

DEPED- DIVISION OF CALAMBA

eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

UNESCO - LEAD
 KAPAYAPAAN YOUTH ORGANIZATION

eparate sheet if necessary)

3/20/2019
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? ________________________________
GOT PREGNANT
________________________________
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
AMALIA DOMINGUIANO BRGY. CANLUBANG CALAMBA CITY 9209693252 3.5 cm. X 4.5 cm
(passport size)

FROILAN DOMINGUIANO BRGY. CANLUBANG CALAMBA CITY 9081622634 With full and handwritten
name tag and signature over
printed name
NOLAN CELO BRGY. CANLUBANG CALAMBA CITY 9197796568
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.: 1245590

Signature (Sign inside the box)
3/20/2019
Date/Place of Issuance: 12/11/2013 LUCENA 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 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