CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

b
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
y
2. SURNAME ANTIGUA
NAME EXTENSION (JR., SR)
by
FIRST NAME NOEL EPHRAIM

F Fili Dual
MIDDLE NAME REYNA

S nat
3. DATE OF BIRTH
12/14/1991 16. CITIZENSHIP
(mm/dd/yyyy) ✘

M e pin b
Citize
W e urali
NASIPIT DISTRICT HOSPITAL,
4. PLACE OF BIRTH If holder of dual citizenship, Pls. indicate country:

Ot
NASIPIT, AGUSAN DEL NORTE

5. SEX
✘ Sia ar
please indicate the details.
o ir
nship
id
hl p 17. RESIDENTIAL ADDRESS
zati PUROK 2

t
6 CIVIL STATUS ✘

ng a
riar
House/Block/Lot No. Street

o on
ABILAN

er
Subdivision/Village Barangay
7. HEIGHT (m)
lee 165
eatl
BUENAVISTA
h AGUSAN DEL NORTE

w
City/Municipality Province

/s
8. WEIGHT (kg) 62 ZIP CODE

dee
18. PERMANENT ADDRESS PUROK 2
9. BLOOD TYPE O

ed
House/Block/Lot No. Street

: ABILAN
10. GSIS ID NO. 66050701647
Subdivision/Village Barangay

d BUENAVISTA AGUSAN DEL NORTE

11. PAG-IBIG ID NO. 1830-0040-6173
City/Municipality Province
12. PHILHEALTH NO. 18-050119084-3 ZIP CODE 8601

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

14. TIN NO. 426-682-102-000 20. MOBILE NO. 09667050889

15. AGENCY EMPLOYEE NO. 1000484 21. E-MAIL ADDRESS (if any) leon_ephraim@yahoo.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME None 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME N/A N/A

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME ANTIGUA

NAME EXTENSION (JR., SR)
FIRST NAME NOEL

MIDDLE NAME MENDOZA

25. MOTHER'S MAIDEN NAME

SURNAME REYNA

FIRST NAME ROSITA

MIDDLE NAME MONTON (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY ABILAN ELEMENTARY SCHOOL PRIMARY EDUCATION 1998 2004 GRADUATE 2004 Valedictorian
VOCATIONAL / BUENAVISTA NATIONAL HIGH
SECONDARY
SCHOOL
HIGH SCHOOL 2004 2008 GRADUATE 2008 Valedictorian

BACHELOR OF SECONDARY EDUCATION-

COLLEGE TRADE PHILIPPINE NORMAL UNIVERSITY 2008 2012 GRADUATE 2012 Cum Laude
COURSE MAJOR IN ENGLISH
FATHER SATURNINO URIOS
GRADUATE STUDIES
UNIVERSITY
BACHELOR OF LAWS 2013 2018 GRADUATE 2018 Cum Laude

(Continue on separate sheet if necessary)

SIGNATURE DATE June 25, 2019

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
PD 907- Honor
Civil Service Professional Graduate

Licensure Examination for Teachers 85.0 9/21/2012 Cagayan de Oro 1173707 12/14/2019

Bar Examinations 80.4 6/17/2019 Manila 72586

(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
SERVICE
28. INCLUSIVE DATES SALARY/ JOB/
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)
October 1,
2016
Present Secondary School Teacher III Department of Education-BCSAT ### 13-1 Permanent Yes
September 20,
May 22, 2013
2016 Secondary School Teacher I Department of Education-BCSAT ### 11-1 Permanent Yes
March 30,
June 1, 2012
2013 College Instructor ACLC College of Butuan ### Contractual No

(Continue on separate sheet if necessary)

SIGNATURE DATE June 24, 2019

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

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

Division Mass Training for Journalism Advisers 7/20/2017 7/23/2017 24.0 Technical Department of Education
Regional Mass Training of Trainers for Journalism
1/9/2016 5/9/2016 40.0 Technical Department of Education
Advisers
Division Mass Training for Journalism Advisers 9/21/2016 9/24/2016 24.0 Technical Department of Education

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 33.
(Write in full) (Write
in full)
Butuan City School of Arts and Trades Faculty,
Journalistic Writing Winning Coach, Division Schools Press Conference Employees, and Retirees Association
Butuan City Public Elementary and Secondary
Technical Writing Winning Coach, Regional Schools Press Conference Teachers, Employees, and Retirees Association

Adobe Photoshop and InDesign

Legal Writing

(Continue on separate sheet if necessary)

SIGNATURE DATE June 24, 2019

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 theof bureau or office or to the person who has immediate supervision over you in the
chief
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? Resigned from 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
Abilan, Buenavista, Agusan del the last 6 months
Marianie R. Balansag Norte
None 3.5 cm. X 4.5 cm
(passport size)
BCSAT, J. Rosales Avenue,
Regina A. Andaya Butuan City
341-72-69 With full and handwritten
name tag and signature over
BCSAT, J. Rosales Avenue, printed name
Remedios F. Umayam Butuan City
341-72-69
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct or photocopied picture
is not acceptable
and 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.: 1173707

Signature (Sign inside the box)
6/24/2019
Date/Place of Issuance: 1/14/2013/Butuan 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 of 4