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 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 SURATOS

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

MIDDLE NAME MIGUEL

3. DATE OF BIRTH
(mm/dd/yyyy) 10/19/1992 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH DAUPAN CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS ZONE 5

House/Block/Lot No. Street
Separat
Widowed BANAOANG WEST
Other/s: ed Subdivision/Village Barangay
7. HEIGHT (m) 1.4478 m MANGALDAN PANGASINAN
City/Municipality Province
8. WEIGHT (kg) 42.7 kg ZIP CODE 2432

9. BLOOD TYPE O+
18. PERMANENT ADDRESS ZONE 6
House/Block/Lot No. Street

10. GSIS ID NO. None ARISTON EAST

Subdivision/Village Barangay
ASINGAN PANGASINAN
11. PAG-IBIG ID NO. 1211-3237-5191
City/Municipality Province

12. PHILHEALTH NO. 01-052020713-4 ZIP CODE 2439

13. SSS NO. 34-4948920-5 19. TELEPHONE NO. (075) 632-5207

14. TIN NO. 470-493-374 20. MOBILE NO. 09306262286

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) roseannsuratos@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

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME SURATOS(+)

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

MIDDLE NAME PETRONA

25. MOTHER'S MAIDEN NAME

SURNAME MIGUEL

FIRST NAME GENEBEA

MIDDLE NAME GOTOC (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

03/30/200
ELEMENTARY MANGALDAN I CENTRAL SCHOOL PRIMARY EDUCATION 06/04/2001 GRADUATED 2006 N/A
6
MANGALDAN NATIONAL HIGH 04/30/201
SECONDARY /
VOCATIONAL SECONDARY 06/05/2006 GRADUATED 2010 N/A
SCHOOL 0

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

TRADE
DON MARIANO MARCOS MEMORIAL BACHELOR OF SECONDARY 03/30/201
COURSE
COLLEGE 06/07/2010 GRADUATED 2014 N/A
STATE UNIVERSITY EDUCATION MAJOR IN FILIPINO 4

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

RA 1080 (TEACHER) 75.2 August 17,2014 ROSALES, PANGASINAN

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

FELIX Y. MANALO SUMMER PRE-

04/02/2018 05/25/2018 FILIPINO TEACHER 0.00 0-0
KINDERGARTEN PROGRAM
06/08/2015 03/31/2017 FILIPINO TEACHER NEW LIFE EDUCATIONAL CENTER INC. 6000.00 0-0
THE PEOPLE OF GOD EXCELLENT
06/04/2014 03/31/2015 FILIPINO TEACHER 3500.00 0-0
ACADEME INC.
 (Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 2
 LICENSE (if applicable)

NUMBER Date of
Validity

1745359 01/31/2019

ue on separate sheet if necessary)

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

SERVICE

STATUS OF
APPOINTMENT

(Y/
N)
VOLUNTEER No

CONTRACTUAL No

CONTRACTUAL No
ue 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
INCLUSIVE DATES
29. NAME & ADDRESS OF ORGANIZATION
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION /
From To

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
ATTENDANCE Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ( Managerial/ CONDUCTED/
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To
JADIE @ NE
TRAINING UNDER MICROSOFT OFFICE 2007 12/26/2016 12/30/2016 40.0
RODRI
JADIE @ NE
TRAINING UNDER MICROSOFT OFFICE 2007 12/17/2016 12/23/2016 56.0
RODRI

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

Computer Literate (Microsoft Office, Excel,

N/A
PowerPoint)
Sports Oriented (Badminton)

Cooking

Gardening

Reading

Writing

(Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

N/A

eparate sheet if necessary)

ROGRAMS ATTENDED
five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

JADIE @ NETLINK INTERNET CAFE / MICHAEL

RODRIGUEZ AND ROMMEL ESPINAS
JADIE @ NETLINK INTERNET CAFE / MICHAEL
RODRIGUEZ AND ROMMEL ESPINAS

eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

N/A
eparate 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? I DECIDED TO APPLY IN THE PUBLIC SCHO
________________________________
________________________________
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 within
the last 6 months
ERNESTO D. PASCUAL BANTOG, ASINGAN, PANGASINAN NONE 3.5 cm. X 4.5 cm
(passport size)
REMIBES D. GARCIA BANTOG, ASINGAN, PANGASINAN NONE With full and handwritten
name tag and signature over
ARISTON EAST, ASINGAN, printed name
BRGY. CAPT. RENE N. VILLANUEVA PANGASINAN
NONE
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 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: PRC

ID/License/Passport No.: 1745359

Signature (Sign inside the box)

Date/Place of Issuance: 1/31/2019 / BAGUIO CITY

Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.

FLORENCIO B. QUEZON JR.

Person Administering Oath

CS FORM 212 (Revised 2017), P

 I DECIDED TO APPLY IN THE PUBLIC SCHOOL.

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