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 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 SAZ
NAME EXTENSION (JR., SR)
FIRST NAME ROVIE
MIDDLE NAME SAZ
3. DATE OF BIRTH
16. CITIZENSHIP Filipino Dual Citizenship
(mm/dd/yyyy) 8/181988 ✘

by
by naturalization
birth
4. PLACE OF BIRTH BADONG, TAGO, SURIGAO DEL SUR If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS ✘ Single Married

17. RESIDENTIAL ADDRESS PUROK MANGGA
Widowed Separated House/Block/Lot No. Street
Other/s: BADONG
Subdivision/Village Barangay
7. HEIGHT (m) 5'4 TAGO SURIGAO DEL SUR
City/Municipality Province
8. WEIGHT (kg) 5O kls ZIP CODE 8301

9. BLOOD TYPE "B+"

18. PERMANENT ADDRESS PUROK MANGGA
House/Block/Lot No. Street
10. GSIS ID NO. 021-1619-6184-1 BADONG
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1211-7563-7888 TAGO SURIGAO DEL SUR

City/Municipality Province
12. PHILHEALTH NO. 18-200940964-6 ZIP CODE 8301

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

14. TIN NO. 481-744-757-000 20. MOBILE NO. 09480449209

15. AGENCY EMPLOYEE NO. L7200261 21. E-MAIL ADDRESS (if any) sazroviegalagar@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

NAME EXTENSION (JR., SR)

FIRST NAME N/A
MIDDLE NAME
OCCUPATION
EMPLOYER/BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.
24. FATHER'S SURNAME SAZ
SR.
FIRST NAME ROVIE
MIDDLE NAME RANES
25. MOTHER'S MAIDEN NAME
SURNAME GALAGAR
FIRST NAME VIRGINIA
MIDDLE NAME MAQUILING (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE SCHOLARSHIP/
26. PERIOD OF ATTENDANCE LEVEL/ YEAR
ACADEMIC
LEVEL (Write in full) UNITS GRADUATED
HONORS
(Write in full) EARNED
RECEIVED
From To (if not graduated)

ELEMENTARY BADONG ELEMENTARY SCHOOL 6/1/1995 3/1/2001 2001

VOCATIONAL /
SECONDARY BADONG NATIONAL HIGH SCHOOL 6/1/2002 3/1/2005 2005

SURIGAO DEL SUR STATE UNIVERSITY ASSOCIATE COMPUTER TECHNOLOGY 6/1/2005 3/30/2006 21 UNITS

BACHELOR OF ART & SCIENCES MAJOR

COLLEGE TRADE SURIGAO DEL SUR STATE UNIVERSITY 6/9/2012 4/7/2015 2015
COURSE IN FILIPINO
MASTER OF ART MAJOR IN FILIPINO
GRADUATE STUDIES SURIGAO DEL SUR STATE UNIVERSITY 6/11/2016 3/30/2018 30 UNITS (CAR)
(MAFLT)
(Continue on separate sheet if necessary)

SIGNATURE DATE June 24, 2019

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

LET (LICENSURE EXAMINATION

78.40% 03/10/2016 CAGAYAN DE ORO CITY
FOR TEACHER)

(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 she
SALARY/ JOB/
28. INCLUSIVE DATES PAY GRADE (if
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY applicable)&
(Write in SALARY STEP (Format
full/Do not abbreviate) (Write in full/Do not abbreviate) "00-0")/
From To INCREMENT

06/13/2016 PRESENT SENIOR HIGH SCHOOL TEACHER II LINGIG NATIONAL HIGH SCHOOL 22,938 N/A

10/01/2014 04/01/2015 PRACTICUM TEACHER CLARENCE TY PIMENTEL NHS N/A N/A

 (Continue on separate sheet if necessary)

SIGNATURE DATE June 24, 2019

CS FORM 212 (Rev
 LICENSE (if applicable)

NUMBER Date of
Validity

10608112 6/13/2016

ue on separate sheet if necessary)

ption of duties should be indicated in the attached Work Experience sheet. GOV'T
SERVICE

STATUS OF
APPOINTMENT

(Y/
N)
PERMANENT Y

VOLUNTER Y
ue on separate sheet if necessary)

June 24, 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) NUMBER OF HOURS POSITION / NAT
(mm/dd/yyyy)
From To

IGLESIA FILIPINA INDEPENDENTE CHURCH (BADONG, TAGO, S.D.S.) 4/5/2019 4/28/2019 VACATION CHURCH

IGLESIA FILIPINA INDEPENDENTE CHURCH (BADONG, TAGO, S.D.S.) 4/3/2018 4/30/2018 VACATION CHURCH

IGLESIA FILIPINA INDEPENDENTE CHURCH (BADONG, TAGO, S.D.S.) 4/1/2017 4/31/2017 VACATION CHURCH

IGLESIA FILIPINA INDEPENDENTE CHURCH (BADONG, TAGO, S.D.S.) 4/20/2016 4/23/2016 VACATION CHURCH

(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/ SPO
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To

3rd DISTRICT RESEARCH CONGRESS 2/21/2019 2/21/2019 8 HRS. DEPED LI

DISTRICT ROLL-OUT ON LRMS MECHANISM AND FRAMEWORK 12/6/2018 12/6/2018 9 HRS. DEPED LI

3 DAY SCHOOL-BASED INSET ON DEVELOPING TEACHING & LEARNING

RESOURCES, PREPARATION OF CLASSROOM FORMS & DOCUMENTS, SPECIAL
10/22/2018 10/24/2018 18 HRS. DEPED LI
LEAVE BENEFITS FOR WOMEN CUM MID-YEAR PROGRAM PERFORMANCE
REVIEW AND EVALUATION

BRGY. DR
THREE DAYS BASIC LIFE SUPPORT TRAINING 6/28/2018 6/30/2018 18 HRS.
BUREAU O

DISTRICT TRAINING WORKSHOP ON THE PPST AND RPMS MANUAL FOR

6/20/2018 6/22/2018 18 HRS. DEPED LI
TEACHERS AND SCHOOL HEADS

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

BNHS (BADON
COMPUTER LITERATE N/A
ALUM

(Continue on separate sheet if necessary)

SIGNATURE DATE J
ENT / PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

VACATION CHURCH SCHOOL TEACHER

VACATION CHURCH SCHOOL TEACHER

VACATION CHURCH SCHOOL TEACHER

VACATION CHURCH SCHOOL TEACHER

separate sheet if necessary)

G PROGRAMS ATTENDED
he last five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

DEPED LINGIG 1 DISTRICT

DEPED LINGIG 1 DISTRICT

DEPED LINGIG NATIONAL PERSONNEL

BRGY. DRR MANAGEMENT COUNCIL AND

BUREAU OF FIRE AND PROTECTION

DEPED LINGIG 1 DISTRICT

separate sheet if necessary)

 MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

BNHS (BADONG NATIONAL HIGH SCHOOL

ALUMNI ASSOCIATION)

separate sheet if necessary)

JUNE 24, 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
chief of bureau or office or to the person who has immediate supervision over you in the Office,
the
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 YES ✘ NO
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, 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? ________________________________
________________________________
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 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
WILLY C. DUMPIT, PhD, FRIdr SCHOOL HEAD, LINGIG NHS 9999666393 3.5 cm. X 4.5 cm
(passport size)

LOURDES O. ORCULLO, EdD PRINCIPAL III, MANDUS NHS 9552997755 With full and handwritten
name tag and signature over
printed name
ALAN S. TIONGSON SHS-ASS. SCHOOL HEAD LNHS 9489726609
Computer generated
42. or photocopied picture
is not acceptable

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.: 1462109 Signature (Sign inside the box)
JUNE 24, 2019
Date/Place of Issuance: 6/14/2016 / PRC BUTUAN 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