CS Form No.
212
Revised 2017
PERSONAL DATA SHEET
mam
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
I. PERSONAL INFORMATION
2. SURNAME MAMON
NAME EXTENSION (JR., SR
FIRST NAME CELEE ANN KRIS
MIDDLE NAME AGUILO
3. DATE OF BIRTH
(mm/dd/yyyy) 11/17/1987 16. CITIZENSHIP Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH OLONGAPO CITY If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male Female
Single Married 17. RESIDENTIAL ADDRESS 65 HAR
6 CIVIL STATUS
Widowed Separated House/Block/Lot No. S
EAST BA
Other/s:
Subdivision/Village Ba
7. HEIGHT (m) 5'2 OLONGAPO CITY ZAM
City/Municipality Pr
8. WEIGHT (kg) 70KG ZIP CODE
18. PERMANENT ADDRESS 65 HAR
9. BLOOD TYPE B+
House/Block/Lot No. S
EAST BA
10. GSIS ID NO.
Subdivision/Village Ba
OLONGAPO CITY
11. PAG-IBIG ID NO. 121181870175
City/Municipality Pr
12. PHILHEALTH NO. 70254900468 ZIP CODE 2200
13. SSS NO. 02-273-0206-0 19. TELEPHONE NO. 222-8430
14. TIN NO. 335-460-170 20. MOBILE NO. 09090265182/09164170549
15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) krislee [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME JANCEL M. DE GUZMAN
MIDDLE NAME
OCCUPATION
EMPLOYER/BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.
24. FATHER'S SURNAME MAMON
NAME EXTENSION (JR., SR)
FIRST NAME CELESTINO
MIDDLE NAME ESCAMILLA
25. MOTHER'S MAIDEN NAME
SURNAME AGUILO
FIRST NAME MARY ANN
MIDDLE NAME FLORES (Continue on separate sheet if necessary
III. EDUCATIONAL BACKGROUND
NAME OF SCHOOL HIGHEST LEVEL/
26. BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE UNITS
LEVEL (Write in EARNED
(Write in full)
full) (if not graduated)
From To
ELEMENTARY EAST BAJAC-BAJAC ELEMENTARY SCHOOL ELEMENTARY 6/22/1999 6/22/2000
SECONDARY ST.JOSEPH HIGHSCHOOL HIGHSCHOOL 6/22/2000 6/22/2004 NONE
VOCATIONAL /
TRADE 4TH
GORDON COLLEGE/ ST.JOSEPH COLLEGE BACHELOR OF SCIENCE IN HOTEL AND RESTAURANT MANAGEMENT/
COURSE
COLLEGE
OLONGAPO-INC
BACHELOR OF SCIENCE IN SECONDARY EDUCATION MAJOR IN
FILIPINO
2004/2013 2008/2015 HONORABLE
MENTION
GRADUATE STUDIES
(Continue on separate sheet if necessary)
SIGNATURE DATE
CS FORM
L DATA SHEET
EFORE ACCOMPLISHING THE PDS FORM.
(Do not fill up. For CSC use only)
NAME EXTENSION (JR., SR)
Dual Citizenship
by naturalization
Pls. indicate country:
HARRIS ST.
Street
EAST BAJAC-BAJAC
Barangay
ZAMBALES
Province
HARRIS ST.
Street
EAST BAJAC-BAJAC
Barangay
ZAMBALES
Province
222-8430
09090265182/09164170549
krislee [email protected]
DATE OF BIRTH (mm/dd/yyyy)
7/24/2010
5/17/1962
11/6/1963
(Continue on separate sheet if necessary)
SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED
2000
2004
4TH
2008-2015 HONORABL
E MENTION
parate sheet if necessary)
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 ap
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
LICENSURE EXAMINATION FOR TEACHERS 9/24/2015 FAMILY CLINIC SAMPALOC MANILA 1414531
(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 SALARY/ JOB/ PAY
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
CENTRAL LUZON COLLEGE OF SCIENCE AND
6/13/2016 4/5/2017 INSTRUCTOR/TEACHER TECHNOLO GY
12000.00
(Continue on separate sheet if necessary)
SIGNATURE DATE
CS FORM 212 (Revised 20
LICENSE (if applicable)
Date of
Validity
arate sheet if necessary)
GOV'T
SERVICE
(Y/
N)
N
arate sheet if necessary)
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 /
From To
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
ATTENDANCE Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ( Managerial/ CONDUCTED/
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To
CENTRAL LU
DRUG PREVENTION AND AWARENESS 11/25/2016 11/25/2016 4.0 MANAGERIAL
TECHNOLOG
CENTRAL L
FIRE AND EARTHQUAKE SEMINAR 11/25/2016 11/25/2016 4.0 MANAGERIAL
PAMBANSANG KUMPERENSIYA SA MAKABAYANG EDUKASYON 10/14/2016 10/16/2016 24.0 MANAGERIAL
CENTRAL L
TEST CONSTRUCTION,TOS, ITEM ANALYSIS 8/12/2016 8/12/2016 8.0 MANAGERIAL
CENTRAL L
ITEM ANALYSIS, INSTRUCTIONAL GUIDE/ WORKSHOP 5/10/2016 5/16/2016 8.0 MANAGERIAL
UPDATING PRE SERVICE AND IN SERVICE TEACHER PEDAGOGICAL COMPETENCIES IN THE
CORE SUBJECT
10/12/2014 10/14/2014 24.0 MANAGERIAL ST.LOIU
INSPIRATIONS AND CHALLENGES OF K-12 12/5/2013 12/7/2013 24.0 MANAGERIAL ST
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
MEMBERS
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)
COOKING, BAKING, SINGING N/A
(Continue on separate sheet if necessary)
SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S
POSITION / NATURE OF WORK
N/A
eparate sheet if necessary)
ROGRAMS ATTENDED
five (5) years for Division Chief/Executive/Managerial positions)
CONDUCTED/ SPONSORED BY
(Write in full)
CENTRAL LUZON COLELGE OF SCIENCE AND
TECHNOLOGY
CENTRAL LUZON COLELGE OF SCIENCE AND
TECHNOLOGY
PUP, MANILA
CENTRAL LUZON COLELGE OF SCIENCE AND
TECHNOLOGY
CENTRAL LUZON COLELGE OF SCIENCE AND
TECHNOLOGY
ST.LOIUE UNIVERSITY, BAGUIO CITY
ST.LOIUE UNIVERSITY, BAGUIO CITY
eparate sheet if necessary)
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)
N/A
eparate sheet if necessary)
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
MR.VALENTIN A. QUIOCHO CELTECH COLLEGE 223-5855 3.5 cm. X 4.5 cm
(passport size)
MR.SAMUEL BUGAYONG COLUMBAN COLLGE 222-3329 With full and handwritten
name tag and signature over
printed name
MS.BRENDA NAPALAN ST.JOSEPH COLLEGE 224-9413
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
is not acceptable
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:
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 o
If YES, give details (country):
, affiant exhibiting his/her validly issued government ID as indicated above.
CS FORM 212 (Revised 2017), Page 4 of 4
