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 ANDRES
NAME EXTENSION (JR., SR) N/A
FIRST NAME PATRICK LLOYD

MIDDLE NAME OTADOY

3. DATE OF BIRTH
3/14/1995 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH TUDELA, CEBU If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS

Widowed House/Block/Lot No. Street

Separate
HALAPITAN
Other/s: d
Subdivision/Village Barangay
SAN FERNANDO BUKIDNON
7. HEIGHT (m) 1.64
City/Municipality Province
8. WEIGHT (kg) 80 ZIP CODE

18. PERMANENT ADDRESS

9. BLOOD TYPE B+
House/Block/Lot No. Street
HALAPITAN
10. GSIS ID NO. N/A
Subdivision/Village Barangay
SAN FERNANDO BUKIDNON
11. PAG-IBIG ID NO. 12005426761
City/Municipality Province

12. PHILHEALTH NO. 15-050459799-9 ZIP CODE 8711

13. SSS NO. 08-2776565-1 19. TELEPHONE NO. N/A

14. TIN NO. 705-478-361-000 20. MOBILE NO. 09051609846

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]
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

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME ANDRES

NAME EXTENSION (JR., SR)
FIRST NAME RIZAL

MIDDLE NAME AMPER JR.

25. MOTHER'S MAIDEN NAME

SURNAME OTADOY

FIRST NAME INNA

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

ELEMENTARY HALAPITAN CENTRAL ELEMENTARY SCHOOL Primary Education 2001 2007 Graduated 2007 N/A

SECONDARY /
VOCATIONAL HALAPITAN NATIONAL HIGH SCHOOL High School Education 2007 2011 Graduated 2011 N/A

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

TRADE
BACHELOR OF SECONDARY EDUCATION
COURSE
COLLEGE CENTRAL MINDANAO UNIVERSITY
MAJOR IN PHYSICS
2013 2017 Graduated 2017 N/A

UNIVERSITY OF SCIENCE AND TECHNOLOGY IN THE MASTER OF SCIENCE IN TEACHING PHYSICAL

GRADUATE STUDIES
PHILIPPINES SCIENCE MAJOR IN PHYSICS
2019 2021 42 UNITS N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE
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

RA 1080 (TEACHER) 84.8 3/25/2018 CAGAYAN DE ORO CITY 1665240 3/14/2024

DRIVER'S LICENSE N/A 12/28/2020 MALAYBALAY CITY K03-20-101049 3/14/2025

(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 SALARY/ JOB/ PAY SERVICE
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
(Y/ N)
LOYOLA HIGH SCHOOL OF DON CARLOS
8/9/2021 5/31/2022 TEACHER 12660.00 03-3 REGULAR N
INC.
LOYOLA HIGH SCHOOL OF DON CARLOS
8/9/2020 5/31/2021 TEACHER 12060.00 02-1 PROBATIONARY N
INC.
LOYOLA HIGH SCHOOL OF DON CARLOS
8/9/2019 5/31/2020 TEACHER 11060.00 00-0 PROBATIONARY N
INC.
LOYOLA HIGH SCHOOL OF DON CARLOS
6/1/2018 3/31/2019 TEACHER 10850.00 00-0 PROBATIONARY N
INC.
LOYOLA HIGH SCHOOL OF DON CARLOS
6/1/2017 3/31/2018 TEACHER 8750.00 00-0 PROBATIONARY N
INC.

(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

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

2021 In-Service Trainging (INSET) for Junior High School Teachers (Additional Runs Online) 3/14/2022 3/16/2022 24.0 Technical Private Education Assistance Committee

2021 In-Service Trainging (INSET) for Senior High School Teachers (Additional Runs Online) 3/7/2022 3/9/2022 24.0 Technical Private Education Assistance Committee

2021 In-Service Trainging (INSET) for Senior High School Teachers 7/15/2021 7/17/2021 24.0 Technical Private Education Assistance Committee

ICT - Based Modalities Under New Normal Education 11/7/2020 12/12/2020 80.0 Technical Advance Computer Mentoring Services

Basic Driving Course 11/19/2020 11/20/2020 16.0 Technical Quicklearn Driving School

2021 In-Service Trainging (INSET) for Senior High School Teachers 10/8/2020 10/10/2020 24.0 Technical Private Education Assistance Committee

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

Computer Literate Philippine Physics Society

Basic Statistics Analysis Bukidnon Physics Society

Basic Computer Troubleshooting

Motorcycle Touring

(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
YES ✘ NO
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 phased If YES, give details:
out (abolition) in the public or private sector? ________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
YES ✘ NO
Barangay election)?
If YES, give details:
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:
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
Mercedes R. Abarquez Dologon, Maramag, Bukidnon 9171606279 4.5 cm. X 3.5 cm
(passport size)

Jay S. Villamil Don Carlos, Bukidnon 9179863416

Computer generated
or photocopied picture
Richmond L. Sumagang Halapitan, San Fernando, Bukidnon 9972051518 is not acceptable

42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct 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 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: PRC

ID/License/Passport No.: 1665240

Signature (Sign inside the box)

Date/Place of Issuance: 7/18/2018 / Cagayan De Oro 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