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 cas
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.

I. PERSONAL INFORMATION
2. SURNAME LUCERNAS

FIRST NAME DINA

MIDDLE NAME CAPINIG

3. DATE OF BIRTH
(mm/dd/yyyy) 12/28/1988 16. CITIZENSHIP Filipino Dual Cit

4. PLACE OF BIRTH POBLACION, AROROY, MASBATE If holder of dual citizenship,

please indicate the details.

5. SEX Male Female

Single Married 17. RESIDENTIAL ADDRESS

6 CIVIL STATUS
Widowed Separated House/Block/Lot No.

Other/s:
Subdivision/Village
CAWAYAN
7. HEIGHT (m) 1.52 m
City/Municipality
8. WEIGHT (kg) 42 kgs ZIP CODE 5409

18. PERMANENT ADDRESS

9. BLOOD TYPE AB+
House/Block/Lot No.

10. GSIS ID NO. 2004698488

Subdivision/Village
CAWAYAN
11. PAG-IBIG ID NO. 1211-5193-4475
City/Municipality

12. PHILHEALTH NO. 10-000112253-8 ZIP CODE 5409

13. SSS NO. NONE 19. TELEPHONE NO. NONE

14. TIN NO. 437-914-520-000 20. MOBILE NO. 9262680419

15. AGENCY EMPLOYEE NO. 5810822 21. E-MAIL ADDRESS (if any) NONE

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME LUCERNAS 23. NAME of CHILDREN (Write full name and list all)
JR MAX DAVE C. LUCERNAS
FIRST NAME MAXIMO

MIDDLE NAME ARRANGUEZ MAX JADE C. LUCERNAS

OCCUPATION APPLICANT MAX DIN C. LUCERNAS

EMPLOYER/BUSINESS NAME NOT APPLICABLE

BUSINESS ADDRESS NOT APPLICABLE

TELEPHONE NO. NOT APPLICABLE

24. FATHER'S SURNAME MALLERNA

NAME EXTENSION (JR., SR)
FIRST NAME RONNIE

MIDDLE NAME OGAYA

25. MOTHER'S MAIDEN NAME CAPINIG

SURNAME MALLERNA

FIRST NAME ERNA

MIDDLE NAME ARGUELLES (Continue on separate sheet i

III. EDUCATIONAL BACKGROUND

26. NAME OF SCHOOL PERIOD OF ATTENDANCE

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

ELEMENTARY CAPSAY ELEMENTARY SCHOOL ELEMENTARY 6/1/1995 3/30/2002

SECONDARY
VOCATIONAL / PANIQUE NATIONAL HIGH SCHOOL SECONDAY 6/1/2002 3/30/2006

NOT APPLICA- NOT APPLICA-

NONE NOT APPLICABLE BLE BLE

TRADE
COURSE DR.EMILIO B. ESPINOSA,SR. MEMORIAL STATE OF BACHELOR IN SECONDARY EDUCATION-
COLLEGE
AGRICULTURE AND TECHNOLOGY ENGLISH
6/1/2007 3/30/2011

GRADUATE STUDIES NONE NOT APPLICABLE NOT APPLICABLE

(Continue on separate sheet if necessary)

SIGNATURE DATE 5/5/2017

AL DATA SHEET
k Experience Sheet shall cause the filing of administrative/criminal case/s against the person

DS) BEFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Filipino Dual Citizenship

by birth by naturalization

Pls. indicate country:

Street
MALBUG
Barangay
MASBATE
Province
5409

Street
CHICO
Barangay
MASBATE
Province

NONE

9262680419

NONE

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

MAX DAVE C. LUCERNAS 10/29/2011

MAX JADE C. LUCERNAS 11/8/2012
MAX DIN C. LUCERNAS 2/15/2017

(Continue on separate sheet if necessary)

HIGHEST LEVEL/ SCHOLARSHIP/

YEAR
UNITS ACADEMIC
GRADUATED
EARNED HONORS
(if not graduated) RECEIVED
 UNITS ACADEMIC
GRADUATED
EARNED HONORS
(if not graduated) RECEIVED

2ND
GRADUATE 3/30/2002
HONORS

GRADUATE 3/30/2006 7TH

NOT NOT
NOT APPLICABLE
APPLICABLE APPLICABLE

GRADUATE 3/30/2011 DIPLOMA

NOT NOT
NOT APPLICABLE
APPLICABLE APPLICABLE

ue 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 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

BOARD FOR PROFESSIONAL TEACHERS 75.2 1/26/2014 LEGAZPI CITY 1301935 7/7/2014

(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/ PAY SERVICE
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
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To
(Y/ N)

1/1/2017 PRESENT TEACHER- 1 MALBUG NATIONAL HIGH SCHOOL 19620.00 11-1 REGULAR YES

1/1/2016 12/31/2016 TEACHER- 1 MALBUG NATIONAL HIGH SCHOOL 19077.00 11-1 REGULAR YES

3/4/2015 12/31/2015 TEACHER- 1 MALBUG NATIONAL HIGH SCHOOL 18549.00 11-1 REGULAR YES

1/1/2015 3/1/2015 TEACHER- 1 NARO NATIONAL HIGH SCHOOL 18549.00 11-1 SUBSTITUTE YES

9/8/2014 11/8/2014 TEACHER- 1 MAYOR TOMAS V. RIVERA MEMORIAL HIGH SCHOOL 18549.00 11-1 SUBSTITUTE YES

6/1/2013 3/30/2014 KINDERGARTEN VOLUNTEER TEACHER CHICO ELEMENTARY SCHOOL 3000.00 CONTRACTUAL YES

6/1/2011 3/31/2012 BARANGAY DAY CARE TEACHER CAPSAY DAY CARE CENTER 2 3000.00 CONTRACTUAL YES

(Continue on separate sheet if necessary)

SIGNATURE DATE 5/5/2017 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 / N
From To

NONE

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

2016 SEMESTRAL BREAK IN-SERVICE TRAINING FOR TEACHERS 10/24/2016 10/28/2016 40 HOURS MANAGERIAL DEPARTMENT

DIVISION VALIDATION WORKSHOP 8/11/2016 8/11/2016 8 HOURS TECHNICAL DEPARTMENT

DIVISIONORIENTATION- CONFERENCE ON CURRICULUM IMPLEMENTATION OF NEW

7/29/2016 7/29/2016 8 HOURS TECHNICAL DEPARTMENT
POLICY GUIDELINES
CAWAYAN SECONDARY SCHOOLS ENHANCEMENT TRAINING ON INSTRUCTIONAL
10/27/2015 10/31/2015 40 HOURS TECHNICAL DEPARTMENT
EFFECTIVENESS AND CLASSROOM MANAGEMENT

TRAINING OF RESULTS-BASED PERFORMANCE MANAGEMENT SYSTEM 9/10/2015 9/11/2015 8 HOURS TECHNICAL DEPARTMENT

REGIONAL MASS TRAINING OF GRADE 10 TEACHERS IN ARALING PANLIPUNAN AND

5/11/2015 5/16/2015 40 HOURS TECHNICAL DEPARTMENT
MAPEH

DISTRICT ROLL- OUT TRAINING ON CHILD PROTECTION 1/22/2015 1/24/2015 24 HOURS TECHNICAL DEPARTMENT

UNIFIED TRAINING ON THE EFFECTIVE IMPLEMENTATION OF SCHOOL- BASED

10/20/2014 10/24/2014 40 HOURS TECHNICAL DEPARTMENT
MANAGEMENT AND ENHANCED K TO 12 BASIC EDUCATION PROGRAM
CAWAYA
COMMUNITY BASED TRAINING PROGRAM IN BASIC MICROSOFT OFFICE 5/4/2014 6/7/2014 80 HOURS TECHNICAL

KINDERGARTEN AND GRADE ONE TEACHERS JOINT CONFERENCE 8/3/2013 8/3/2013 8 HOURS TECHNICAL DEPARTMENT

DEPARTMENT
NEW DAY CARE TEACHERS TRAINING 4/25/2011 1/29/2011 40 HOURS TECHNICAL
DEVELOPMEN

(Continue on separate sheet if necessary)

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

SINGING AND CHOREOGRAPHY NONE

(Continue on separate sheet if necessary)

SIGNATURE DATE 5/5/2017

/ VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

rate sheet if necessary)

S ATTENDED
) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

CAWAYAN LIVELIHOOD AND TECHNICAL

TRAINING CENTER

DEPARTMENT OF EDUCATION

DEPARTMENT OF SOCIAL WELFARE AND

DEVELOPMENT

rate sheet if necessary)

 MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

NONE

rate sheet if necessary)

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 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? ________________________________
FINISHED CONTRACT
________________________________
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
the last 6 mon
NANCY A. BALDIA MALBUG, CAWAYAN, MASBATE 9063564430 3.5 cm. X 4.5
(passport siz

ANECITO I. ABAYON CAWAYAN, MASBATE 9071872434 With full and hand

name tag and signa
printed nam
PETER N. FERRARIS MALINTA, MASBATE 9096130409
Computer gener
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete or photocopied p
is not accepta
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 PHOTO
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.: 1301935

Signature (Sign inside the box)

Date/Place of Issuance: 7/7/2014/LEGAZPI CITY

Date Accomplished Right Thumbma

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated
Person Administering Oath

CS FORM 212 (Revised

 If YES, give details:
________________________________

If YES, give details:

________________________________
________________________________

If YES, give details:

________________________________
________________________________

If YES, give details:

________________________________
________________________________

If YES, give details:

________________________________
FINISHED CONTRACT
________________________________
NO

NO

NO
If YES, give details (country):

NO

NO

NO

ID picture taken within

the last 6 months
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten

name tag and signature over
printed name

Computer generated
or photocopied picture
is not acceptable

PHOTO

Right Thumbmark

, affiant exhibiting his/her validly issued government ID as indicated above.

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