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 agai

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 PULALON
NAME EXTENSION (JR., SR)
FIRST NAME MERIYAM

MIDDLE NAME HAJIJUL

3. DATE OF BIRTH
16. CITIZENSHIP √ Filipino Dual Citizen
(mm/dd/yyyy)
12/15/1997 √ by birth
4. PLACE OF BIRTH ARENA BLANCO, Z.C. If holder of dual citizenship, Pls. indicate country
please indicate the details.
5. SEX Male √ Female

√ Single Married 17. RESIDENTIAL ADDRESS N/A 6TH

6 CIVIL STATUS
Widowed Separated
House/Block/Lot No.
N/A
Other/s: Subdivision/Village
ZAMBOANGA CITY Z
7. HEIGHT (m) 5'1
City/Municipality
8. WEIGHT (kg) 38 kg ZIP CODE 7000
18. PERMANENT ADDRESS N/A 6TH
9. BLOOD TYPE B
House/Block/Lot No.
N/A
10. GSIS ID NO. N/A
Subdivision/Village
ZAMBOANGA CITY
11. PAG-IBIG ID NO. N/A
City/Municipality
12. PHILHEALTH NO. N/A ZIP CODE 7000

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

14. TIN NO. N/A 20. MOBILE NO. +63 935-774-2744

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) meriyam.pulalon@gmail.c
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME N/A N/A

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME PULALON

NAME EXTENSION (JR., SR)
FIRST NAME SAID N/A

MIDDLE NAME JUMAHARI

25. MOTHER'S MAIDEN NAME

SURNAME HAJIJUL

FIRST NAME PARIDJAM

MIDDLE NAME SALAM (Continue on separate sheet if necess

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL HIGHEST LEVEL/
26. BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE UNITS
LEVEL EARNED
(Write in full)
(Write in full) (if not graduated)
From To
ARENA BLANCO ELEMENTARY
ELEMENTARY
SCHOOL EAST
BASIC EDUCATION 6/28/2004 3/30/2010 GRADUATED
ARENA BLANCO NATIONAL HIGH
SECONDARY
VOCATIONAL / SCHOOL
BASIC EDUCATION 6/7/2010 3/31/2014 GRADUATED

TESDA-ARMM LANGUAGE SKILL

INSTITUTE
ENGLISH LANGUAGE AND CULTURE 1/7/2019 2/11/2019 GRADUATED
TRADE
COURSE
 WESTERN MINDANAO STATE BACHELOR OF ELEMENTARY EDUCATION
COLLEGE
UNIVERSITY MAJOR IN EARLY CHILDHOOD EDUCATION
6/4/2014 4/4/2018 GRADUATED

GRADUATE STUDIES N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE
/s against the person concerned.

(Do not fill up. For CSC use only)

., SR)

Citizenship
irth by naturalization
country: PHILIPPINES

6TH STREET BENCH DRIVE

Street
ARENA BLANCO
Barangay
ZAMBOANGA DEL SUR
Province

6TH STREET BENCH DRIVE

Street
ARENA BLANCO
Barangay
ZAMBOANGA DEL SUR
Province

744
mail.com

DATE OF BIRTH (mm/dd/yyyy)

N/A

if necessary)

SCHOLARSHIP/
YEAR GRADUATED ACADEMIC HONORS
RECEIVED

1ST
2010 HONORABLE
MENTION
2ND
2014 HONORABLE
MENTION
2019 N/A
 2018 N/A

N/A N/A

January 28, 2020

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

RA 1080 (Board) 79.0 3/24/2019 ZAMBOANGA CITY 1175144

(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/
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY PAY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To

7/5/2019 8/3/2019 Grade 5 Substitute Teacher Tugbungan Elementary School 20754.00 SG 2 N/A
Don Gregorio Evangelista Memorial
8/5/2019 9/5/2019 Kindergarten Substitute Teacher 20754.00 SG 2 N/A
School
Don Gregorio Evangelista Memorial
10/25/2019 1/24/2020 Kindergarten Substitute Teacher 20754.00 SG 2 N/A
School

(Continue on separate sheet if necessary)

SIGNATURE DATE January 28, 2020

CS FORM 212 (Revised 2017
 LICENSE (if applicable)

Date of
Validity

12/15/22

ate sheet if necessary)

uties should be indicated in the attached Work Experience sheet.

GOV'T SERVICE

(Y/
N)

N/A

N/A

N/A

ate sheet if necessary)

January 28, 2020

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) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

N/A 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
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) Technical/etc)
From To

ENGLISH LANGUAGE AND CULTURE 1/7/2019 2/11/2019 100-hours TECHNICAL TESDA-ARMM LANGUAGE SKILL INSTITUTE

COMPUTER AND INFORMATION TECHNOLOGY 1/3/2018 3/28/2018 30-hours TECHNICAL CIT-SOUTHERN CITY COLLEGES
On Job Training as Assistant Student in
4/1/2018 4/29/2018 1 month TECHNICAL CIT-SOUTHERN CITY COLLEGES
Information Technology Crash Course Program
International Training Series On New Trends In SOUTHEAST ASIA INSTITUTE OF
10/11/2019 10/13/2019 3 days MANAGERIAL
Education EDUCATIONAL TRAINING,INC

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 33.
(Write in full)
(Write in full)
Philippine Association For Teachers &
Teaching Pedagogy N/A
Educator (PAFTE), Inc.
Creative Drawing

(Continue on separate sheet if necessary)

SIGNATURE DATE January 28, 2020

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 theof bureau or office or to the person who has immediate supervision over you in the
chief
Office,
Bureau or Department where you will be apppointed,
a. within the third degree? Yes √ No
b. within the fourth degree (for Local Government Unit - Career Employees)? Yes √ No
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
c. Are you a solo parent? If YES, please specify ID No:
Yes √ No
If YES, please specify ID No: _

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAME ADDRESS TEL. NO.

WESTERN MINDANAO STATE

Mrs.Marisol Tubo UNIVERSITY
0916-745-9597

WESTERN MINDANAO STATE

Mrs. Jennee A. Valencia UNIVERSITY-ILS
0926-842-2850

BALIWASAN, ZAMBOANGA
Ms.Pinky L. Alimuddin CITY
0935-048-5493

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 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 LICENSE

ID/License/Passport No.: 1175144

Signature (Sign inside the box)
January 28, 2020
Date/Place of Issuance: 06-17-19/Zamboanga City
Date Accomplished R

SUBSCRIBED AND SWORN to before me this August 6, 2019 , affiant exhibiting his/her validly issued government ID as indicated above.
Person Administering Oath
 If YES, give details: ________________________________
________________________________

If YES, give details: ________________________________

________________________________

If YES, give details: ________________________________

________________________________

If YES, give details: ________________________________

________________________________

If YES, give details: ________________________________

________________________________

If YES, give details (country):

If YES, please specify: __________________

If YES, please specify ID No: __________________

If YES, please specify ID No: ___________________

PHOTO

Right Thumbmark

overnment ID as indicated above.

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