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 BULACLAC
NAME EXTENSION([Link].) N/A
FIRST NAME FERRIE JOY

MIDDLE NAME ENCARNACION

3. DATE OF BIRTH
(mm/dd/yyyy) 12/16/1995 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH ROXAS ORIENTAL MINDORO If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS LOT 38/40 BLK 5 SEC.4 N/A
House/Block/Lot No. Street
Widowed Separate
d BELVEDERE PARADAHAN 1
Other/s:
Subdivision/Village Barangay

7. HEIGHT (m) 162.56 TANZA CAVITE

City/Municipality Province
8. WEIGHT (kg) 55 ZIP CODE 4108

9. BLOOD TYPE A 18. PERMANENT ADDRESS LOT 38/40 BLK 5 SEC.4 N/A
House/Block/Lot No. Street

10. GSIS ID NO.

BELVEDERE PARADAHAN 1
Subdivision/Village Barangay

11. PAG-IBIG ID NO.

TANZA CAVITE
City/Municipality Province

12. PHILHEALTH NO. ZIP CODE 4108

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

14. TIN NO. 20. MOBILE NO. 09468938885

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) bulaclacferriejoy@[Link]
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)
FIRST NAME N/A N/A N/A N/A

MIDDLE NAME N/A N/A N/A

OCCUPATION N/A N/A N/A

EMPLOYER/BUSINESS NAME N/A N/A N/A

BUSINESS ADDRESS N/A N/A N/A

TELEPHONE NO. N/A N/A N/A

24. FATHER'S SURNAME BULACLAC N/A N/A

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

MIDDLE NAME MARTINEZ N/A N/A

25. MOTHER'S MAIDEN NAME FERLIE FANCUBIT ENCARNACION N/A N/A

SURNAME ENCARNACION N/A N/A

FIRST NAME FERLIE N/A N/A

MIDDLE NAME FANCUBIT (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY DANGAY ELEMENTARY SCHOOL ELEMENTARY 2002 2008 N/A 2008 N/A

SECONDARY DANGAY NATIONAL HIGH SCHOOL HIGH SCHOOL 2008 2013 N/A 2013 N/A
VOCATIONAL /

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

TRADE
COURSE
COLLEGE JOHN PAUL COLLEGE ELEMENTARY 2013 2017 N/A 2017 N/A

MASTER OF ARTS IN EDUCATION MAJOR IN

GRADUATE STUDIES PACIFIC INTERCONTINENTAL COLLEGE EDUCATIONAL MANAGEMENT 2023 PRESENT N/A N/A N/A
A

SIGNATURE DATE June 25, 2024

CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER RATING DATE OF
SPECIAL LAWS/ CES/ CSEE (If Applicable) EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT NUMBER Date of
Validity

LICENSURE EXAMINATION FOR TEACHERS 09/30/2018 CALAPAN ORIENTAL MINDORO 12/16/2025

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

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

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

(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
28. INCLUSIVE DATES SERVICE
SALARY/ JOB/ PAY
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
MONTHLY STATUS OF
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To (Y/ N)

08/072024 PRESENT TEACHER I AMAYA ELEMENTARY SCHOOL 27,000 11-1 PERMANENT Y

09/01/2023 PRESENT LSB TEACHER PARADAHAN ELEMENTARY SCHOOL 10,000.00 N/A CONTRACTUAL N

12/06/2019 03/04/2022 TEACHER I MARCELO I. CABRERA VHS 20,754.00 11-1 SUBSTITUTE Y

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

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

(Continue on separate sheet if necessary)
SIGNATURE DATE June 25, 2024
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 / NATURE OF WORK
From To

NEW ERA UNIVERSITY 09/21/2020 10/26/2020 60 VOLUNTEER TEACHER

NEW ERA UNIVERSITY 04/03/2017 05/30/2017 60 VOLUNTEER TEACHER

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

From To

SCHOOL LEARNING ACTION CELL 01/24/2024 01/26/2024 40 TECHNICAL PARADAHAN ELEMENTARY SCHOOL

SCHOOL SEMINAR ON GENDER AND DEVELOPMENT RELATED LAWS 11/18/2023 11/18/2023 8 TECHNICAL PARADAHAN ELEMENTARY SCHOOL

E-LEARNING & TEACHING RESOURCE MATERIALS IN THE DIGITAL WORLD 05/20/2019 05/30/2019 120 TECHNICAL JOHN PAUL COLLGE
TRAINING COURSE

EMPOWERING K-12 TEACHERS THROUGH CLASSROOM TEACHING AND 10/29/2018 1031/2018 24 TECHNICAL SAN VICENTE NATIONAL HIGH SCHOOL
EVALUATION

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

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(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. NON-ACADEMIC DISTINCTIONS / RECOGNITION (Write in full) 33. (Write in
full)

COMPUTER LITERATE N/A N/A

READING AND WRITING 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

(Continue on separate sheet if necessary)
SIGNATURE DATE June 25, 2024
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 ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘

If YES, give details:

________________________________
N/A

35. a. Have you ever been found guilty of any administrative offense?
YES ✘ NO
If YES, give details:
________________________________
N/A
________________________________

b. Have you been criminally charged before any court? YES ✘ NO

If YES, give details:
________________________________
Date Filed:
________________________________ N/A
Status of Case/s: N/A
36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation
by any court or tribunal? YES ✘ NO
If YES, give details:
________________________________
N/A
________________________________
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 ✘ YES NO
out (abolition) in the public or private sector? If YES, give details:
________________________________
RESIGNATION
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? YES ✘ NO
If YES, give details: N/A
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: N/A
39. Have you acquired the status of an immigrant or permanent resident of another country?
YES ✘ NO
If YES, give details (country):
N/A
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: N/A
b. Are you a person with disability? YES ✘ NO
If YES, please specify ID No: N/A
c. Are you a solo parent?
YES ✘ NO
If YES, please specify ID No: N/A

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

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
MARY JANE C. CORTUNA PARADAHAN 1 TANZA CAVITE 9458520428 3.5 cm. X 4.5 cm
(passport size)

MARICEL V. CADIZ GENERAL TRIAS CAVITE 9292621571 With full and handwritten
name tag and signature over
printed name
GRACE G. QUIACOS AMADIO TANZA CAVITE 9508272907
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
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable
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
administrative/criminal case/s against me. PHOTO

Government Issued ID ([Link], GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of
Issuance
Government Issued ID: PRC LICENSE

ID/License/Passport No.:
Signature (Sign inside the box)
06/25/2024
Date/Place of Issuance: 01/07/2019 PRC LUCENA Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this 26th day of June, 2024 , affiant exhibiting his/her validly issued government ID as indicated above.

REA C. FAMORCAN,EdD
Principal IV
Person Administering Oath

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