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 c

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 SALAM
FIRST NAME SAMIRA
MIDDLE NAME ARUH
3. DATE OF BIRTH
(mm/dd/yyyy) JULY 10,1987 16. CITIZENSHIP

4. PLACE OF BIRTH LAMITAN CITY,BASILAN If holder of dual citizenship,

please indicate the details.

5. SEX FEMALE

17. RESIDENTIAL ADDRESS

6 CIVIL STATUS SINGLE
House/Block/Lot No.

Subdivision/Village
7. HEIGHT (m) 1.64 m LAMITAN CITY
City/Municipality
8. WEIGHT (kg) 60 kg ZIP CODE 7302
18. PERMANENT ADDRESS
9. BLOOD TYPE A
House/Block/Lot No.

10. GSIS ID NO. 2004232359

Subdivision/Village

11. PAG-IBIG ID NO. 1210-6134-7963 LAMITAN CITY

City/Municipality

12. PHILHEALTH NO. 20-000011024-7 ZIP CODE 7302

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 935-143-306 20. MOBILE NO.

15. AGENCY EMPLOYEE NO. 0860420 21. E-MAIL ADDRESS (if any) SAMIR

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all)

NAME EXTENSION (JR., SR)

FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME YAHIYA

NAME EXTENSION (JR.,
FIRST NAME SALAM SR)
MIDDLE NAME HASILUN
25. MOTHER'S MAIDEN NAME

SURNAME ARUH
FIRST NAME HAMJALIYA
MIDDLE NAME HADJE (Contin
III. EDUCATIONAL BACKGROUND

26. NAME OF SCHOOL PERIOD OF ATTENDANCE

BASIC EDUCATION/DEGREE/COURSE
LEVEL (Write in
(Write in full)
full)
From To

MAGSAYSAY ELEMENTARY
ELEMENTARY ELEMENTARY 1994 2000
SCHOOL

SECONDARY LAMITAN NATIONAL HIGH SCHOOL SECONDARY 2000 2004

VOCATIONAL /

TRADE
COURSE
BACHELOR OF SCIENCE IN
BASILAN STATE COLLEGE 2004 2008
SECONDARY EDUCATION
COLLEGE

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE
NAL DATA SHEET
eet shall cause the filing of administrative/criminal case/s against the person concerned.

COMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Pls. indicate country:

Street
BATO
Barangay
BASILAN
Province
7302

Street
BATO
Barangay
BASILAN
Province

09169504321
SAMIRASALAM87@GMAIL.COM

23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

(Continue on separate sheet if necessary)

 HIGHEST LEVEL/ YEAR
UNITS EARNED GRADUATED SCHOLARSHIP/ ACADEMIC HONORS RECEIVED
(if not graduated)

GRADUATED 2000

GRADUATED 2004

GRADUATED 2008

nue on separate sheet if necessary)

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
LICENSURE EXAMINATION FOR APRIL
76% ZBGA. CITY HIGH SCHOOL WEST
TEACHERS 18,2010

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

03/01/2011 05-31-11 SST-1 DEPARTMENT OF EDUCATION 20000.00 STEP 3

06/01/2011 SST-1 DEPARTMENT OF EDUCATION 20,000.00 STEP 3

(Continue on separate sheet if necessary)

SIGNATURE DATE
 LICENSE (if applicable)
Date of
NUMBER Validity

1062137 07/10/2022

on separate sheet if necessary)

should be indicated in the attached Work Experience sheet.

GOV'T SERVICE

STATUS OF APPOINTMENT

(Y/ N)

REG. PERMANENT YES

REG.PERMANENT YES

on separate 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
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29.
(Write in full) (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

30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS (mm/dd/yyyy)
(Write in full)

From To

2 day in service training on test item development 6-28-2011 06-29-2011

K12 Basic Education Curriculum Cluster 5 day mass training for garde 8 teachers May 03,2013
04-29-2013
K12 Basic Education Curriculum Cluster 5 day mass training for grade 9 teachers 05-26-2014 05-30-2014

5 Day Division Training on Dynamic Learning Program 06-25-2012 06-29-2012

READ ALLL-Training for teachers in reading and writing 07-20-2015 07-24-2015

5 Day Training on Dynamic Learning Program 05-17-2015 05-21-2015

2 Day Roll Out on Results-Based Performance Management System (RPMS) and Philippine Professional Standards for Teachers (PPST) 02-27-2019 02-28-2019

American English (AE) Seminar 10/04/2018

 (Continue on separate sheet if necessary)
VIII. OTHER INFORMATION

SPECIAL SKILLS and NON-ACADEMIC DISTINCTIONS / RECOGNITION

31. 32.
HOBBIES (Write in full)

(Continue on separate sheet if necessary)

SIGNATURE
ORGANIZATION/S

NUMBER OF HOURS POSITION / NATURE OF WORK

eparate sheet if necessary)

ecutive/Managerial positions)

Type of LD
( Managerial/
NUMBER OF HOURS
Supervisory/
CONDUCTED/ SPONSORED BY (Write in full)
Technical/etc)

16 hours Deped-Armm

40 hours Deped-Armm

40 hours Deped-Armm

40 hours SMART
40 hours BEAM

40 hours SMART

16 hours Deped-Armm

8 hours
American English Foundation
parate sheet if necessary)

OGNITION MEMBERSHIP IN ASSOCIATION/ORGANIZATION

33. (Write in full)
(Write in full)

parate sheet if necessary)

DATE
CS FORM 212 (Revised 2017), Page 3 of 4
 34. ..
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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
________________________________

35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
________________________________

b. Have you been criminally charged before any court?

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?
If YES, give details:
________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation,
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
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before 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?
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?
If YES, please specify: YAKAN
b. Are you a person with disability?
If YES, please specify ID No:
c. Are you a solo parent?
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
3.5 cm. X 4.5 cm
OMAR J. MOHAWAN TIPO-TIPO,BASILAN 9266448689 (passport size)

With full and handwritten

name tag and signature over
printed name

Computer generated
or photocopied picture
is not acceptable
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct 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 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:

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

JULY 03,2019
Date/Place of Issuance: 04-05-2016
Date/Place of Issuance: 04-05-2016 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

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