Professional Documents
Culture Documents
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 BULAGNIR
15. AGENCY EMPLOYEE NO. 6291558 21. E-MAIL ADDRESS (if any) genward.bulagnir@g
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) N/A
FIRST NAME N/A
SECONDARY CATUBIG VALLEY NATIONAL HIGH SCHOOL HIGH SCHOOL 6/5/2006 4/5/2010
VOCATIONAL /
TRADE
COURSE UNIVERSITY OF EASTERN PHILIPPINES, PEDRO
COLLEGE
REBADULLA MEMORIAL CAMPUS CATUBIG
BACHELOR OF SECONDARY EDUCATION 6/7/2010 3/31/2014
SIGNATURE DATE
AL DATA SHEET
k Experience Sheet shall cause the filing of administrative/criminal case/s against the person
NONE
by birth by naturalization
N/A
Street
RAMA
Barangay
SAMAR
Province
6418
N/A
Street
CANUCTAN
Barangay
NORHTERN SAMAR
Province
6418
NONE
09056533657
genward.bulagnir@gmail.com
23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A N/A
N/A N/A
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 STATUS OF
(Write in full/Do (Write in SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) full/Do not abbreviate) INCREMENT
From To
SEASONAL
11/25/2014 11/14/2015 RECEIVING CLERCK RIVERA MERCANTILE SYSTEM INC. 12.000.00 N/A CONTRACUAL
(Continue on separate sheet if necessary)
Date of
Validity
10/5/2017
GOV'T
SERVICE
(Y/ N)
YES
YES
NO
NO
eparate sheet if necessary)
ICT NONE
VOLLEY BALL NONE
CHESS NONE
WUSHU NONE
SIGNATURE DATE
E / VOLUNTARY ORGANIZATION/S
NONE
CONDUCTED/ SPONSORED BY
(Write in full)
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in
full)
NONE
NONE
NONE
NONE
NONE
4/28/2017
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
a. Have you ever been found guilty of any administrative offense? YES NO
35.
39. Have you acquired the status of an immigrant or permanent resident of another country?
If YES, give details (country):
40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA YES NO
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?
If YES, please specify ID No:
PEPITO ADARAYAN CATUBIG, NORTHERN SAMAR 9262159221 With full and han
name tag and sign
printed nam
Computer gene
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied p
is not accept
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.
SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated
Computer generated
or photocopied picture
is not acceptable
PHOTO
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