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 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 SUMAGDON

FIRST NAME ANTOLEN NAME EXTENSION (JR., SR) JR.

MIDDLE NAME NAVALES
3. DATE OF BIRTH
(mm/dd/yyyy) 02/10/1990 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH METRO, MANILA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS ✘ Single Married17. RESIDENTIAL ADDRESS
Widowed Separat House/Block/Lot No. Street

Other/s: ed PALALE
Subdivision/Village Barangay

7. HEIGHT (m) 1.57 STA. MARGARITA SAMAR
City/Municipality Province
8. WEIGHT (kg) 48 ZIP CODE 6709

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

10. GSIS ID NO. 2005091741 PALALE
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121172396855 STA. MARGARITA SAMAR
City/Municipality Province

12. PHILHEALTH NO. 130501405605 ZIP CODE 6709

13. SSS NO. 06-3223116-6 19. TELEPHONE NO. NONE

14. TIN NO. 490-918-528-000 20. MOBILE NO. 09362132505

15. AGENCY EMPLOYEE NO. 6293527 21. E-MAIL ADDRESS (if any) antholinnavales@gmail.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) NONE
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME SUMAGDON
NAME EXTENSION (JR., SR)
FIRST NAME ANTOLEN
SR.,

MIDDLE NAME

25. MOTHER'S MAIDEN NAME

SURNAME NAVALES

FIRST NAME EMMA

MIDDLE NAME SABARIA (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 GRADUATED
(Write in full) EARNED HONORS
full) (if not graduated) RECEIVED
From To

ELEMENTARY SOLSOGON ELEMENTARY SCHOOL PRIMARY EDUCATION 1997 2005 N/A 2005

CALBAYOG CITY NATIONAL HIGH
SECONDARY /
VOCATIONAL HIGH SCHOOL 2005 2010 N/A 2010
SCHOOL

NONE
TRADE
BACHELOR OF SCIENCE IN INDUSTRIAL
COURSE
COLLEGE NORTHWEST SAMAR STATE UNIVERSITY TECHNOLOGY MAJOR IN ELECTRONICS
2010 2014 N/A 2014

MASTER TECHNICIAN IN EDUCATION MAJOR IN
GRADUATE STUDIES SAMAR STATE UNIVERSITY ELECTRONICS TECHNOLOGY
2014 2016 36 UNITS N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE 02/03/2017 CS FORM 212 (Revised 2017), Page 1 of 4

CS FORM 212 (Revised 2017), Page 1 of 4

COFFEE AND WINE 9500. CIVIL SERVICE ELIGIBILITY 27. NIÑO NATIONAL 06/15/2016 PRESENT TECHNICAL -VOCATIONAL TRACK ) HIGH SCHOOL/ SENIOR HIGH SCHOOL 21387. DEPARTMENT OF EDUCATION/STO. 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 NONE (Continue on separate sheet if necessary) V.00 12-1 05/04/2013 06/10/2016 CHEF DEMETRIUS' BREAD. SALARY/ JOB/ 28. WORK EXPERIENCE (Include private employment. COFFEE AND WINE 6000.00 N/A . Start from your recent work) Description of duties should be indicated in the attached Work Experience sheet. INCLUSIVE DATES PAY GRADE (if POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY (mm/dd/yyyy) MONTHLY applicable)& (Write in full/Do not (Write in SALARY STEP (Format abbreviate) full/Do not abbreviate) "00-0")/ From To INCREMENT TEACHER II (SENIOR HIGH SCHOOL .IV.00 N/A 12/10/2010 06/13/2013 BARTENDING AND FOOD ATTENDANT DEMETRIUS' BREAD.

(Continue on separate sheet if necessary) SIGNATURE DATE 05/03/2017 CS FORM 212 (Re CS FORM 2 .

LICENSE (if applicable) NUMBER Date of Validity e on separate sheet if necessary) of duties should be indicated in the attached Work Experience sheet. GOV'T SERVICE STATUS OF APPOINTMENT (Y/ N) PROVISIONAL Y PERMANENT N PERMANENT N .

e on separate sheet if necessary) CS FORM 212 (Revised 2017). Page 2 of 4 CS FORM 212 (Revised 2017). Page 2 of 4 .

NAME & ADDRESS OF ORGANIZATION (Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK From To NONE (Continue on separate sheet if necessary) VII.NIŇO NATIONAL HIGH SCHOOL I IN SHIELDED METAL ARC WELDING NATIONAL TVET TRAINER CERTICATE LEVEL VOLLEYBALL CERTIFICATE OF RECOGNITION AS COACH IN 2016 DIVISION FESTIVAL OF TALENT-TECHNOLYMPIC I IN BREAD AND PASTRY PRODUCTION CERTIFICATE OF APPRECIATION AS TRAINER TECHNOLOGY AND LIVELIHOOD EDUCATION SCHOOL COOKING SKILL COMPETITION AT STO. 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. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S INCLUSIVE DATES 29. OTHER INFORMATION MEMBERSHIP IN ASSOCIATION/ORGANIZATION NON-ACADEMIC DISTINCTIONS / RECOGNITION 31. SPECIAL SKILLS and HOBBIES 32. Page 3 of 4 . TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ( Managerial/ CONDUCTED/ SPONSORED BY NUMBER OF HOURS (Write in full) (mm/dd/yyyy) Supervisory/ (Write in full) Technical/etc) From To JOB ORIENTATION FOR NEWLY HIRED SENIOR HIGH SCHOOL TEACHERS 03/01/2017 03/03/2017 24 TECHNICAL DEPARTMENT OF EDUCATION TECHNICAL EDUCATION AND SKILL DEVELOPMENT NATIONAL CERTIFICATE II IN COOKERY ( AMMENDED) 05/10/2016 06/08/2016 436 TECHNICAL AUTHORITY TECHNICAL EDUCATION AND SKILL DEVELOPMENT NATIONAL CERTIFICATE II IN FOOD AND BEVERAGE SERVICES ( AMMENDED) 05/10/2016 06/07/2016 336 TECHNICAL AUTHORITY MASS TRAINING OF TEACHER FOR SENIOR HIGH SCHOOL GRADE 11 ( TVL TRACK) 06/20/2016 06/28/2016 72 TECHNICAL DEPARTMENT OF EDUCATION SENIOR HIGH SCHOOL GRADE 11 MASS TRAINING OF TEACHER (COMMON 07/02/2016 07/05/2016 32 TECHNICAL DEPARTMENT OF EDUCATION TOPIC ) TECHNICAL EDUCATION AND SKILL NATIONAL CERTIFICATE II IN ELECTRICAL INSTALLATION AND MAINTENACE 12/01/2015 12/20/2015 80 TECHNICAL DEVELOPMENT AUTHORITY TECHNICAL EDUCATION AND SKILL TRAINERS METHODOLOGY CERTIFICATE I 10/02/2015 11/21/2015 123 TECHNICAL DEVELOPMENT AUTHORITY TECHNICAL EDUCATION AND SKILL NATIONAL CERTIFICATE II IN BREAD AND PASTRY PRODUCTION 09/10/2013 10/20/2013 141 TECHNICAL DEVELOPMENT AUTHORITY TECHNICAL EDUCATION AND SKILL NATIONAL CERTIFICATE II IN BARTENDING 08/10/2013 09/05/2013 286 TECHNICAL DEVELOPMENT AUTHORITY TECHNICAL EDUCATION AND SKILL NATIONAL CERTIFICATE II IN HOUSEKEEPING 08/10/2013 09/10/2013 436 TECHNICAL DEVELOPMENT AUTHORITY TECHNICAL EDUCATION AND SKILL NATIONAL CERTIFICATE II IN COMMERCIAL COOKING 11/20/2012 01/015/2013 436 TECHNICAL DEVELOPMENT AUTHORITY NATIONAL CERTIFICATE II IN FOOD AND TECHNICAL EDUCATION AND SKILL 11/20/2012 01/15/2013 336 TECHNICAL BEVERAGE DEVELOPMENT AUTHORITY NATIONAL CERTIFICATE II IN SHEILDED TECHNICAL EDUCATION AND SKILL 06/10/2012 08/25/2012 268 TECHNICAL METAL ARC WELDING DEVELOPMENT AUTHORITY (Continue on separate sheet if necessary) VIII. (Write in (Write in full) full) CERTIFICATE OF RECOGNITION AS RESOURCE SPEAKER IN CAREER GUIDANCE ORIENTATION NATIONAL TVET TRAINER CERTICATE LEVEL COMPUTER LITERATE PROGRAM IN STO. 33.NIŇO NATIONAL HIGH SCHOOL (Continue on separate sheet if necessary) SIGNATURE DATE 05/03/2017 CS FORM 212 (Revised 2017).VI.

Page 4 of 4 . within the third degree? YES ✘ NO b. affiant exhibiting his/her validly issued government ID as indicated above. 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. a. Are you a solo parent? YES ✘ NO If YES. NO. please specify ID No: 41. Pursuant to: (a) Indigenous People's Act (RA 8371). BALUD CALBAYOG CITY 9772079775 With full and handwritten name tag and signature over printed name Computer generated 42. PRC. X 4. termination.) PLEASE INDICATE ID Number and Date of Issuance Government Issued ID: BIR TIN ID/License/Passport No.5 cm.: 490-918-528-200 Signature (Sign inside the box) 05/03/2017 Date/Place of Issuance: 10/06/2016/CATBALOGAN CITY Date Accomplished Right Thumbmark SUBSCRIBED AND SWORN to before me this . (b) Magna Carta for Disabled Persons (RA 7277). please answer the following items: a. Driver's License. or to the chief of bureau or office or to the person who has immediate supervision over you in the Office.5 cm (passport size) MS.Career Employees)? YES ✘ NO If YES. 34. dismissal. Have you been criminally charged before any court? YES ✘ NO If YES. Government Issued ID (i. a. give details: b. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee) NAME ADDRESS TEL. YES ✘ NO retirement.DEBORAH A. decree. give details: ________________________________ Date Filed: ________________________________ Status of Case/s: 36.BALUD CALBAYOG CITY 9173160725 3. Are you a person with disability? YES ✘ NO If YES. ordinance or regulation YES ✘ NO by any court or tribunal? If YES. give details: ________________________________ ________________________________ 37. rules and regulations of the Republic of the Philippines. Have you ever been separated from the service in any of the following modes: resignation. Person Administering Oath CS FORM 212 (Revised 2017). a. Are you related by consanguinity or affinity to the appointing or recommending authority. GSIS. and (c) Solo Parents Welfare Act of 2000 (RA 8972).Passport. within the fourth degree (for Local Government Unit . Have you ever been a candidate in a national or local election held within the last year (except YES ✘ NO Barangay election)? If YES. DEMETRIO C. please specify ID No: c. Bureau or Department where you will be apppointed. please specify: b. I authorize the agency head/authorized representative to verify/validate the contents stated herein. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true. Have you ever been found guilty of any administrative offense? YES ✘ NO If YES. give details (country): 40. SSS. etc. DIMARANAN BRGY. Are you a member of any indigenous group? YES ✘ NO If YES. give details: ________________________________ 35. end of term. Have you acquired the status of an immigrant or permanent resident of another country? YES ✘ NO If YES. ID picture taken within the last 6 months MR. dropped from the rolls. give details: out (abolition) in the public or private sector? ________________________________ ________________________________ 38.e. correct and or photocopied picture is not acceptable complete statement pursuant to the provisions of pertinent laws. finished contract or phased If YES. Have you ever been convicted of any crime or violation of any law. DIMARANAN BRGY. I agree that any misrepresentation made in this document and its attachments shall cause the filing of PHOTO administrative/criminal case/s against me. give details: ________________________________ ________________________________ b. give details: 39.