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 GAUM
NAME EXTENSION (JR., SR)
FIRST NAME JHOMERIX

MIDDLE NAME DELFIN

3. DATE OF BIRTH
8/19/1995 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH MONTE DUJALI, KAPALONG, DDN 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 LAWA-AN

Widowed Separate House/Block/Lot No. Street

MONTE DUJALI
Other/s: d Subdivision/Village Barangay
SAN ISIDRO DAVAO DEL NORTE
7. HEIGHT (m) 5'2
City/Municipality Province
8. WEIGHT (kg) 65 ZIP CODE 8121
18. PERMANENT ADDRESS PUROK LAWA-AN
9. BLOOD TYPE B+
House/Block/Lot No. Street
MONTE DUJALI
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1212-2925-3167 SAN ISIDRO DAVAO DEL NORTE

City/Municipality Province
12. PHILHEALTH NO. 16-050774000-3 ZIP CODE 8121

13. SSS NO. 09-4433889-6 19. TELEPHONE NO. N/A

14. TIN NO. 347-131-856-000 20. MOBILE NO. +639613905824

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) jhomerixgaum@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) N/A
FIRST NAME N/A N/A
N/A
MIDDLE NAME N/A N/A
N/A
OCCUPATION N/A N/A
N/A
EMPLOYER/BUSINESS NAME N/A N/A
N/A
BUSINESS ADDRESS N/A N/A
N/A
TELEPHONE NO. N/A N/A
N/A
24. FATHER'S SURNAME GAUM N/A
NAME EXTENSION (JR., SR) N/A
FIRST NAME RENATO N/A
N/AA
MIDDLE NAME SUGALA N/A
N/A
25. MOTHER'S MAIDEN NAME N/A
N/A
SURNAME DELFIN N/A
N/A
FIRST NAME MERCIDITA N/A

MIDDLE NAME TENGAS (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY GOV. DUJALI ELEMENTARY SCHOOL PRIMARY EDUCATION 2002 2009 N/A 2009 4TH HONOR

VOCATIONAL DATU BALONG NATIONAL HIGH

SECONDARY / HIGH SCHOOL 2009 2013 N/A 2013 3RD HONOR
SCHOOL
TECHNICALEDUCATION AND SKILLS
AUTHORITY
FRONT OFFICE SERVICES NCII N/A 2019 N/A
TRADE BACHELOR OF SECONDARY EDUCATION MAJOR
COLLEGE
COURSE ST. MARY'S COLLEGE OF TAGUM INC.
IN FILIPINO
2013 2018 N/A 2018 N/A

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

(Continue on separate sheet if necessary)

SIGNATURE DATE
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 applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity

LICENSURE EXAMINATION FOR TEACHER 84.0 09/29/201 DAVAO CITY 1793380 8/19/2022

(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.
GOV'T
28. INCLUSIVE DATES SALARY/ JOB/ SERVICE
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY PAY GRADE (if STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To
(Y/ N)
FILIPINO TEACHER ELEMENTARY ASSUMPTA SCHOOL OF TAGUM CONTRACTUA
6/14/2018 4/30/2019 12000.00 N/A L
N/A
(GRADE 4, 5 AND 6) INCORPORATED
FILIPINO TEACHER JUNIOR HIGH ASSUMPTA SCHOOL OF TAGUM CONTRACTUA
16/17/2019 3/31/2020 1200.00 N/A L
N/A
SCHOOL INCORPORATED
 (Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENTINCLUSIVE
IN CIVICDATES
/ NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION
29. NUMBER OF
(Write in full) HOURS POSITION / NATURE OF WORK
(mm/dd/yyyy)
From To

N/A N/A N/A N/A N/A

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

THE ART OF QUESTIONING, VALUES INTEGRATION AND

CLASSROOM MANAGEMENT
8/24/2018 1/25/2018 16.0 N/A ASSUMPTION COLLEGE OF NABUNTURAN

THE JOURNEY OF INQUIRY: A SEMINAR-WORKSHOP ON

MODERN RESEARCH PRACTICES IN EDUCATION
3/16/2019 3/17/2019 16.0 N/A YOUNG EDUCATORS CONVERGENCE OF SOCCSKSAR

BASIC EDUCATION COACHES FORMATION 8/31/2019 8/31/2019 8.0 N/A DIOCESAN APOSTOLATE ON CATHOLIC EDUCATION OF TAGUM

DSPC 2018 ADVISERS SEMINAR WORKSHOP 10/7/2018 10/9/2018 24.0 N/A DIVISION OF TAGUM CITY

THE USE OF VARIED ASSESSMENT TOOLS IN-

1/31/2020 1/31/2020 8.0 N/A ASSUMPTA SCHOOL OF TAGUM INC.
DEPTH TREATMENT OF CONTENT

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

SINGING N/A N/A

DIOCESAN APOSTOLATE ON CATHOLIC EDUCATION OF
TECHNICAL OFFICIAL OF CSAA 2019
TAGUM
ASSUMPTA SCHOOL OF TAGUM COM. ARTS ENGLISH
JUDGE DURING COM. ARTS FEAST '19
CLUB
2ND PLACE NEWS WRITING ELEM. - FILIPINO DIVISION SCHOOLS PRESS CONFERENCE - TAGUM
COACH DIVISION
2ND PLACE EDITORIAL CARTOONING DIVISION SCHOOLS PRESS CONFERENCE - TAGUM
ELEM. - FILIPINO COACH DIVISION
3RD PLACE EDITORIAL WRITING ELEM. - DIVISION SCHOOLS PRESS CONFERENCE - TAGUM
FILIPINO COACH DIVISION
3RD PLACE PHOTOJOURNALISM ELEM. - DIVISION SCHOOLS PRESS CONFERENCE - TAGUM
FILIPINO COACH DIVISION
4TH PLACE SPORTS WRITING ELEM. - DIVISION SCHOOLS PRESS CONFERENCE - TAGUM
FILIPINO COACH DIVISION
5TH PLACE FEATURE WRITING ELEM. - DIVISION SCHOOLS PRESS CONFERENCE - TAGUM
COACH DIVISION
4TH PLACE SCI-TECH WRITING ELEM. - DIVISION SCHOOLS PRESS CONFERENCE - TAGUM
FILIPINO COACH DIVISION
6TH PLACE COPYREADING & HEADLINE DIVISION SCHOOLS PRESS CONFERENCE - TAGUM
WRITING ELEM. - FILIPINO COACH DIVISION
DIVISION MATHEMATICS & SCIENCE QUEST &
1ST PLACE GRADE 7 SCIDUKO COACH
INTERACTIVE SKILLS COMPETITION - TAGUM CITY
DIVISION MATHEMATICS & SCIENCE QUEST &
2ND PLACE GRADE 9 SCIDUKO COACH
INTERACTIVE SKILLS COMPETITION - TAGUM CITY
 DIVISION MATHEMATICS & SCIENCE QUEST &
3RD PLACE GRADE 8 SCIDUKO COACH
INTERACTIVE SKILLS COMPETITION - TAGUM CITY
DIVISION MATHEMATICS & SCIENCE QUEST &
4TH PLACE GRADE 8 SCIDUKO COACH
INTERACTIVE SKILLS COMPETITION - TAGUM CITY
DIVISION MATHEMATICS & SCIENCE QUEST &
3RD PLACE GRADE 7 SCIDUKO COACH
INTERACTIVE SKILLS COMPETITION - TAGUM CITY
DIVISION MATHEMATICS & SCIENCE QUEST &
3RD PLACE GRADE 9 SCIDUKO COACH
INTERACTIVE SKILLS COMPETITION - TAGUM CITY
(Continue on separate sheet if necessary)

SIGNATURE DATE
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 ✘ 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
a.
items:
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
Sr. JULIE P. ROMA, fma TAGUM CITY 9197963465 3.5 cm. X 4.5 cm
(passport size)

GEMINNIE MARABE, RN, LPT TAGUM CITY 9199041941 With full and handwritten
name tag and signature over
printed name
FELMERY COQUILLA, Ed.D. TAGUM CITY 9398292575
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 PHOTO
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

ID/License/Passport No.: 1793380

Signature (Sign inside the box)
 Date/Place of Issuance: 07/09/2019
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 of 4