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 aga
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

I. PERSONAL INFORMATION
2. SURNAME MINO
NAME EXTENSION (JR., SR
FIRST NAME ZESA

MIDDLE NAME SION A

3. DATE OF BIRTH
(mm/dd/yyyy) 5/13/1992 16. CITIZENSHIP Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH MAASIN, SOUTHERN LEYTE If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male Female

Single Married 17. RESIDENTIAL ADDRESS DULLA

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. S
SAN
Other/s:
Subdivision/Village Ba
TOMAS OPPUS SOUTH
7. HEIGHT (m) 1.57m
City/Municipality Pr
8. WEIGHT (kg) 45 KG ZIP CODE 6605

18. PERMANENT ADDRESS DULLA

9. BLOOD TYPE AB
House/Block/Lot No. S
SAN
10. GSIS ID NO. 02004326169
Subdivision/Village Ba
TOMAS OPPUS
11. PAG-IBIG ID NO. 1211-0808-6280
City/Municipality Pr

12. PHILHEALTH NO. 13-000111805-1 ZIP CODE 6605

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

14. TIN NO. 426-904-047 20. MOBILE NO. 09551725627

15. AGENCY EMPLOYEE NO. 4654240 21. E-MAIL ADDRESS (if any) keepsolstice@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME MINO 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) N/A
FIRST NAME RAMSIE

MIDDLE NAME BIA

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME SIONA

FIRST NAME JOSEPH

MIDDLE NAME TACLE

25. MOTHER'S MAIDEN NAME

SURNAME ARRO

FIRST NAME ZENAIDA

MIDDLE NAME TIMKANG (Continue on separate sheet if necessary

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY SAN ISIDRO ELEMENTARY SCHOOL ELEMENTARY 6/8/1998 3/31/2004 GRADUATED

SECONDARY DON AGUSTIN F. ESCAO NATIONAL HIGH SCHOOL SECONDARY 6/7/2004 3/28/2008 GRADUATED
VOCATIONAL /

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

TRADE
SOUTHERN LEYTE STATE UNIVERSITY- TOMAS BACHELOR OF SECONDARY EDUCATION-
COURSE
COLLEGE
OPPUS ENGLISH
6/9/2008 3/30/2012 GRADUATED

SOUTHERN LEYTE STATE UNIVERSITY- TOMAS

GRADUATE STUDIES
OPPUS
MASTER OF ARTS IN EDUCATION - ENGLISH 4/16/2012 3/30/2016 GRADUATED
(Continue on separate sheet if necessary)

SIGNATURE DATE JUN

CS FORM
l case/s against the person

(Do not fill up. For CSC use only)

ENSION (JR., SR)

zenship

by naturalization

indicate country:

DULLA STREET
Street
SAN ISIDRO
Barangay
SOUTHERN LEYTE
Province

DULLA STREET
Street
SAN ISIDRO
Barangay
SOUTHERN LEYTE
Province

mail.com

DATE OF BIRTH (mm/dd/yyyy)

N/A

et if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2004 N/A

2008 N/A
 N/A N/A

2012 N/A

2016 N/A

JUNE 4,2017

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

LICENSURE EXAMINATION FOR TEACHERS 81.2 9/30/2012 TACLOBAN CITY 1173100

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

GRADE 12 REGULAR
1/1/2017 PRESENT TEACHER II SHS DEPED/SOGOD NATIONAL HIGH SCHOOL 21626.00
STEP 1 PERMANENT
GRADE 12 REGULAR
6/13/2016 12/31/2016 TEACHER II SHS DEPED/SOGOD NATIONAL HIGH SCHOOL 20651.00
STEP 1 PERMANENT
GRADE 11 REGULAR
6/3/2016 6/12/2016 TEACHER I DEPED/SOGOD NATIONAL HIGH SCHOOL 19286.00
STEP 2 PERMANENT
GRADE 11 REGULAR
1/1/2016 6/2/2016 TEACHER I DEPED/SOGOD NATIONAL HIGH SCHOOL 19077.00
STEP 2 PERMANENT
SALARY
REGULAR
6/3/2013 12/31/2015 TEACHER I DEPED/SOGOD NATIONAL HIGH SCHOOL 18549.00 GRADE 11
PERMANENT
STEP 1
SOUTHERN LEYTE STATE UNIVERSITY - TOMAS
6/11/2012 10/19/2012 VISITING INSTRUCTOR 18000.00 N/A CONTRACTUAL
OPPUS
 (Continue on separate sheet if necessary)

SIGNATURE DATE JUNE 4, 2017

CS FORM 212 (Revised 20

 LICENSE (if applicable)

Date of
Validity

5/13/2018

eet if necessary)

GOV'T
SERVICE

(Y/
N)
YES

YES

YES

YES

YES

YES
eet if necessary)

JUNE 4, 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 /
From To

N/A NA NA NA

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

SEMINAR WORKSHOP ON COMPREHENSIVE LAND USE PLAN 1/30/2017 1/31/2017 16.0 TECHNICAL LOCAL

SCHOOL BASE MPRE INSET 2016 10/24/2016 10/28/2016 40.0 TECHNICAL SOGO

DIVISION TRAINING WORKSHOP ON CONTINUOUS IMPROVEMENT 10/19/2016 10/21/2016 24.0 TECHNICAL DI

MTOT FOR SHS GRADE 11 ACADEMIC TRACK 5/25/2016 6/11/2016 144.0 TECHNICAL

SHS GRADE 11 MTOT COMMON TOPIC 5/16/2016 5/19/2016 32.0 TECHNICAL

SCHOOL BASE MPRE INSET 2015 10/26/2015 10/30/2015 40.0 TECHNICAL SO

SCHOOL BASE TRAINING ON ASSESSING TEACHERS ACESS TO LRMDS 7/31/2015 7/31/2015 8.0 TECHNICAL SO

DIVISION BASE RGIONAL K TO 12 MASS TRAINING FOR GRADE 10 TEACHERS 5/4/2015 5/9/2015 40.0 TECHNICAL DIVIS

CHRISTIAN EDUCATION - TEACHERS TRAINING SEMINAR 4/9/2015 4/11/2015 40.0 TECHNICAL IGL

SCHOOL BASED INSET ON PROFESSIONAL GROWTH 10/22/2014 9/14/2014 24.0 TECHNICAL SO

SEMINAR ON CHILDRENS LEGAL RIGHTS AND LIMITATIONS 9/7/2014 9/14/2014 16.0 TECHNICAL SOUTHERN LE

DIVISION BASED TEACHER INDUCTION PROGRAM 8/29/2014 8/31/2014 24.0 TECHNICAL DI

VIII. OTHER INFORMATION

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

CREATIVE WRITING

HOSTING

ORGANIZING EVENTS

SIGNATURE DATE
EOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

NA

rate sheet if necessary)

GRAMS ATTENDED

e (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

LOCAL GOVERNMENT UNIT - SOGOD

SOGOD NATIONAL HIGH SCHOOL

DIVISION OF SOUTHERN LEYTE

DEPED REGION VIII

DEPED REGION VIII

SOGOD NATIONAL HIGH SCHOOL

SOGOD NATIONAL HIGH SCHOOL

DIVISION OF SOUTHERN LEYTE

IGLESIA FILIPINA INDEPENDIENTE

SOGOD NATIONAL HIGH SCHOOL

SOUTHERN LEYTE STATE UNIVERSITY - TOMAS OPPUS

DIVISION OF SOUTHERN LEYTE

R INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)
 N/A

JUNE 4, 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

If YES, give details:

________________________________
a. Have you ever been found guilty of any administrative offense? YES NO
________________________________
35.

If YES, give details:

________________________________
________________________________
YES NO
b. Have you been criminally charged before any court?
If YES, give details:
________________________________
Date Filed:
________________________________
Status of Case/s:
YES NO
36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation
by any court or tribunal?
If YES, give details:
________________________________
YES NO
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation,
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? ________________________________
YES NO
________________________________
END OF CONTRACT AS A TEACHER AT SLSU - TO

a. Have you ever been a candidate in a national or local election held within the last year (except
38. Barangay election)? YES NO

If YES, give details:

b. Have you resigned from the government service during the three (3)-month period before the last
election to promote/actively campaign for a national or local candidate? YES NO
If YES, give details:
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:

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

NAME ADDRESS TEL. NO.

ID picture taken within
STA. SOFIA, PADRE BURGOS, the last 6 months
RT. REV. ARLY M. BALILI SOUTHERN LEYTE
9468551302 3.5 cm. X 4.5 cm
(passport size)
RIZAL, MACROHON, SOUTHERN
ATTY. AEMILDA B. MADREDIJO LEYTE
9177910723 With full and handwritten
name tag and signature over
MANTAHAN, MAASIN CITY, printed name
DR. VIOLETA B. FELISILDA SOUTHERN LEYTE LEYTE
9065293377
Computer generated
or photocopied picture
 name tag and signature over
printed name

Computer generated
42. or photocopied picture
I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and 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: TIN

ID/License/Passport No.: 426-904-047

Signature (Sign inside the box)

Date/Place of Issuance: 02/11/2016 MAASIN CITY

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 o

 END OF CONTRACT AS A TEACHER AT SLSU - TO

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