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 LIBATIQUE
NAME EXTENSION (JR., SR)
FIRST NAME HELEN GRACE
MIDDLE NAME CABANILLA
3. DATE OF BIRTH
(mm/dd/yyyy) 16. CITIZENSHIP
3/13/1982 ✘ Filipino Dual Citizenship
✘ by birth
by
4. PLACE OF BIRTH DIFFUN, QUIRINO If holder of dual citizenship, Pls. indicate country: naturalization
please indicate the details.
5. SEX
Male ✘ Female
17. RESIDENTIAL ADDRESS
6 CIVIL STATUS Single ✘ Married House/Block/Lot No. Street
Widowed Separated AURORA WEST
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 4'11 DIFFUN QUIRINO
City/Municipality Province
8. WEIGHT (kg) 73 Kls ZIP CODE
18. PERMANENT ADDRESS
9. BLOOD TYPE 0
House/Block/Lot No. Street
10. GSIS ID NO. CRN -021-1539-8937-8 AURORA WEST
Subdivision/Village Barangay
11. PAG-IBIG ID NO. 121049985679 DIFFUN QUIRINO
City/Municipality Province
12. PHILHEALTH NO. 06-050138778 ZIP CODE
13. SSS NO. N/A 19. TELEPHONE NO.
14. TIN NO. 423-859-373-000 20. MOBILE NO.
15. AGENCY EMPLOYEE NO. 0030475 21. E-MAIL ADDRESS (if any)
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME LIBATIQUE 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME FREDDIERICK N/A N/A
MIDDLE NAME OREIRO
OCCUPATION SELF-EMPLOYED
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME CABANILLA
NAME EXTENSION (JR., SR)
FIRST NAME VIRGILIO
MIDDLE NAME SARMUYAN
25. MOTHER'S MAIDEN NAME
SURNAME TILLES ( DECEASED )
FIRST NAME ELVIRA
MIDDLE NAME ESPANYOL (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
HIGHEST LEVEL/
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE
UNITS
YEAR SCHOLARSHIP/
LEVEL (Write in full) (Write in full) GRADUATED ACADEMIC HONORS
EARNED RECEIVED
(if not graduated)
From To
ELEMENTARY DIFFUN CENTRAL SCHOOL ELEMENTARY 1989 1996 Graduated 1996 NONE
SECONDARY QUIRINO STATE COLLE LAB. HS HIGH SCHOOL 1996 1999 Graduated 1999 CUA
VOCATIONAL /
N/A N/A N/A N/A N/A N/A N/A
TRADE
COURSE
COLLEGE QUIRINO STATE COLLEGE BACHELOR IN ELEMENTARY 1999 2003 Graduated 2003 N/A
EDUCATION
GRADUATE STUDIES
QUIRINO STATE UNIVERISTY/ MAED/ PHD 2012 2015 Graduated 2015 N/A
NORTHEASTER COLLEGE 2015 2017 2017
(Continue on separate sheet if necessary)
SIGNATURE DATE
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
SPECIAL LAWS/ CES/ CSEE (If Applicable) DATE OF EXAMINATION / CONFERMENT PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY / DRIVER'S LICENSE NUMBER Date of
Validity
LICENSURE EXAMINATION FOR TEACHERS 79.80 3/11/2012 TUGUEGARAO CITY 1131269 3/13/2027
( LET)
(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 GOV'T SERVICE
SALARY/ JOB/ PAY
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if STATUS OF
(Write in full/Do not MONTHLY SALARY applicable)& STEP
APPOINTMENT
(Write in full/Do not abbreviate) abbreviate) (Format "00-0")/
INCREMENT (Y/
From To N)
1/1/2023 PRESENT MASTER TEACHER 1 DEPARTMENT OF EDUCATION ₱560,700.00 18 PERMANENT YES
10/11/2022 12/31/2022 MASTER TEACHER 1 DEPARTMENT OF EDUCATION ₱542,436.00 18 PERMANENT YES
1/1/2022 10/10/2022 TEACHER 3 DEPARTMENT OF EDUCATION ₱365,124.00 13 PERMANENT YES
6/1/2021 12/31/2021 TEACHER 3 DEPARTMENT OF EDUCATION ₱346,860.00 13 PERMANENT YES
1/1/2021 5/31/2021 TEACHER 3 DEPARTMENT OF EDUCATION ₱343,068.00 13 PERMANENT YES
1/1/2020 12/31/2020 TEACHER 3 DEPARTMENT OF EDUCATION ₱324,804.00 13 PERMANENT YES
1/1/2019 12/31/2019 TEACHER 3 DEPARTMENT OF EDUCATION ₱306,540.00 13 PERMANENT YES
6/1/2018 12/31/2018
(Continue on separate sheet if necessary)
SIGNATURE DATE
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
(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/ CONDUCTED/ SPONSORED BY
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To
(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)
(Continue on separate sheet if necessary)
SIGNATURE DATE
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:
________________________________
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 regulation
by any court or tribunal? YES NO
If YES, give details:
________________________________
________________________________
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:
________________________________
________________________________
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:
b. Have you resigned from the government service during the three (3)-month period before the last YES
election to promote/actively campaign for a national or local candidate? NO
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 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?
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
the last 6 months
3.5 cm. X 4.5 cm
(passport size)
With full and handwritten
name tag and signature over
printed name
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 (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)
PLEASE INDICATE ID Number and Date of
Issuance
Government Issued ID:
ID/License/Passport No.:
Signature (Sign inside the box)
Date/Place of Issuance:
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
