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 ABAJAR
NAME EXTENSION (JR., SR)
FIRST NAME JACKY BELLE

MIDDLE NAME PALMA

3. DATE OF BIRTH
(mm/dd/yyyy)
4/2/1989 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH ZNAC, TAMPILISAN, Z.N. 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

Separated ZNAC
Other/s:
Subdivision/Village Barangay
TAMPILISAN ZAMBOANGA DEL NORTE
7. HEIGHT (m) 4'11
City/Municipality Province
8. WEIGHT (kg) 52 ZIP CODE

18. PERMANENT ADDRESS

9. BLOOD TYPE O+
House/Block/Lot No. Street
ZNAC
10. GSIS ID NO. 02004465264
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121003981337 TAMPILISAN ZAMBOANGA DEL NORTE

City/Municipality Province

12. PHILHEALTH NO. 14-050133487-8 ZIP CODE 7116

13. SSS NO. 10-0898312-8 19. TELEPHONE NO. N/A

14. TIN NO. 295-167-689 20. MOBILE NO. 09273090163

15. AGENCY EMPLOYEE NO. 5340064 21. E-MAIL ADDRESS (if any) [email protected]/[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 JERICHO JAY P. ABAJAR 9/2/2004

MIDDLE NAME

OCCUPATION N/A

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME ABAJAR

NAME EXTENSION (JR., SR)
FIRST NAME MIGUEL

MIDDLE NAME MACADILDIG

25. MOTHER'S MAIDEN NAME

SURNAME PALMA

FIRST NAME THELMA

MIDDLE NAME OVALO (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
HONORS
(Write in full)
full) (if not graduated) RECEIVED
From To

ELEMENTARY ZNAC ELEMENTARY SCHOOL ELEMENTARY 1995 2001 GRADUATED 2001-2002 W/ HONOR
VOCATIONAL /
SECONDARY JRMSU - LABORATORY HIGH SCHOOL SECONDARY 2001 2006 GRADUATED 2005-2006 W/ HONOR
N/A N/A N/A N/A N/A N/A N/A
COLLEGE TRADE JRMSU - TC/WMSU ESU IPIL BS IN COMPUTER SCIENCE-IT/PECC - MAJOR TLE 2006/2012 2010/2013 GRADUATED 2009-2010 NONE
COURSE

GRADUATE STUDIES SAINT VINCENT COLLEGE EMD 2019 PRESENT 42 UNITS N/A NONE
(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

LICENSURE EXAMINATION FOR TEACHERS 0.8 3/1/2013 ZAMBOANGA CITY 1202342 2024

(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)

1/23/2021 PRESENT TEACHER III TAMPILISAN NHS 29000.00 SG 13-1 PERMANENT Y

6/5/2017 1/23/2017 TEACHER II TAMPILISAN NHS 21387.00 SG12-1 PERMANENT Y

1/1/2017 6/517 TEACHER I TAMPILISAN NHS 19620.00 SG11-1 PERMANENT Y

12/28/2016 1/1/2017 TEACHER I TAMPILISAN NHS 19077.00 SG11-1 PERMANENT Y

1/1/2016 12/28/2016 TEACHER I TAMPILISAN NHS 19077.00 SG11-1 PERMANENT Y

1/1/2015 1/1/2016 TEACHER I TAMPILISAN NHS 18549.00 SG11-1 PERMANENT Y

1/1/2014 1/1/2015 TEACHER I TAMPILISAN NHS 18549.00 SG11-1 PERMANENT Y

7/23/2013 12/31/2013 TEACHER I TAMPILISAN NHS 18549.00 SG11-1 PERMANENT Y

(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
(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/ SPONSORED BY
NUMBER OF HOURS
(Write in full) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To

TAMPILISAN DISTRICT BASED INSERVICE TRAINING 10/22/2018 10/26/2018 40 DEPARTMENT OF EDUCATION

JOINT SIMULTANEOUS BSP/GSP DISTRICT CAMP 2018 8/24/2018 8/26/2028 24 BSP/GSP

4DAY LIVE IN NATIONAL TRAINING AN WORKSHOP ON MUSIC, ARTS, PHYSICAL DEPARTMENT OF EDUCATION AND NATIONAL
EDUCATION AND HEALTH MAPEH OF THE NATIONAL ASSOCIATION OF PHYSICAL 5/4/2018 5/7/2018 40 ASSOCIATION OF PHYSICAL EDUCATORS A.T.
EDUCATORS ANCHETA ENTERPRISES

CD3 MOBILE CLUSTER -DISTRICT GRADE 11 AND 12 CAREER GUIDANCE PROGRAM DEPARTMENT OF EDUCATION
5/3/2018 5/4/2018 16
(CGP) MANUAL ROLL OUT TRAINING
BSP
10TH WESTERN MINDANAO BOYS SCOUT OF THE PHILIPPINES JAMBOREE 2/28/2018 3/4/2018 64

(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)

DANCING EUPHORIAN DANCE TROUPE ASSISTANT COACH ALPHA SIGMA PHI

COOKING JUNIOR SCHOOL BAND COORDINATOR KARANCHO

(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: ON PROCESS

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

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
MARCIANO C. CABABAT POB. TAMPILISAN Z.N 9171152136 3.5 cm. X 4.5 cm
(passport size)

EVELYN J. ROCHA ZNAC TAMPILSAN Z.N 9269054791 With full and handwritten
name tag and signature over
printed name
ANNABEL A. QUINES GATAS KALAWIT Z.N 9263523493
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: UNID

ID/License/Passport No.: 021132750272

Signature (Sign inside the box)

Date/Place of Issuance: 2013 - DIPOLOG 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