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 AÑONUEVO
FIRST NAME NIKKA NAME EXTENSION (JR., SR) N/A
MIDDLE NAME TAPAT
3. DATE OF BIRTH
(mm/dd/yyyy) 3/3/1995 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH DASMARIÑAS,CAVITE If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female
6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS 155 KAPANTAYAN
Widowed Separated House/Block/Lot No. Street
N/A BUCAL 1
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 4'11 MARAGONDON CAVITE
City/Municipality Province
8. WEIGHT (kg) 68 ZIP CODE 4112
9. BLOOD TYPE O
18. PERMANENT ADDRESS 155 KAPANTAYAN
House/Block/Lot No. Street
10. GSIS ID NO. N/A N/A BUCAL 1
Subdivision/Village Barangay
MARAGONDON CAVITE
11. PAG-IBIG ID NO. 12144711227
City/Municipality Province
12. PHILHEALTH NO. 080259675387 ZIP CODE 4112
13. SSS NO. 3451732827 19. TELEPHONE NO. 4191167
14. TIN NO. 470161782000 20. MOBILE NO. 09984672957
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 N/A
MIDDLE NAME N/A
OCCUPATION N/A
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME AÑONUEVO
NAME EXTENSION (JR., SR)
FIRST NAME TOMASITO N/A
MIDDLE NAME SISAYAN
25. MOTHER'S MAIDEN NAME N/A
SURNAME TAPAT
FIRST NAME ROSALINDA
MIDDLE NAME LINEZO (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
NAME OF SCHOOL HIGHEST LEVEL/ SCHOLARSHIP/
YEAR
BASIC EDUCATION/DEGREE/COURSE UNITS ACADEMIC
LEVEL (Write in EARNED
GRADUATED
HONORS
(Write in full)
full) (if not graduated) RECEIVED
From To
ELEMENTARY BUCAL 1, ELEMENTARY SCHOOL ELEMENTARY 2001 2007 N/A 2007 N/A
SECONDARY
VOCATIONAL / BUCAL NATIONAL HIGH SCHOOL HIGH SCHOOL 2007 2011 N/A 2011 N/A
N/A N/A N/A N/A N/A N/A N/A
TRADE
POLYTECHNIC UNIVERSITY OF THE PHILIPPINES- BACHELOR IN SECONDARY EDUCATION MAJOR
COURSE
COLLEGE
MARAGONDON IN ENGLISH 2011 2015 N/A 2015 N/A
GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)
SIGNATURE DATE JUNE 05,2023
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 EXAM FOR TEACHERS 75.4 2/9/2022 MANILA 1985609 3/3/2026
(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)
1/10/2018 04/20/2020 ELEMENTARY/HIGH SCHOOL TEACHER NEW SKY CENTER,VIETNAM ₱50,000.00 N/A CONTRACTUAL N/A
1/9/2017 09/30/2018 ELEMENTARY/HIGH SCHOOL TEACHER LACVIET ENGLISH CENTER,VIETNAM ₱40,000.00 N/A CONTRACTUAL N/A
1/6/2015 03/30/2017 HIGH SCHOOL TEACHER SAINT GREGORY ACADEMY ₱8,000.00 N/A CONTRACTUAL N/A
1/6/2015 03/30/2017 HIGH SCHOOL TEACHER SAINT GREGORY ACADEMY ₱8,000.00 N/A CONTRACTUAL 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 05,2023
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
(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) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To
EFFECTIVE ENGLISH PROFICIENCY 10/1/2023 01/21/2023 80 TECHNICAL ELTECH LEARNING HUB
TESOL METHODOLOGY MOOC 2002 05/31/2022 9/6/2022 8 TECHNICAL ONLINE PROFESSIONAL ENGLISH NETWORK
N/A N/A N/A N/A N/A N/A
(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 N/A N/A
N/A N/A N/A
(Continue on separate sheet if necessary)
SIGNATURE DATE JUNE 05,2023
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
YES ✘ NO
by any court or tribunal?
If YES, give details:
________________________________
N/A
________________________________
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? ________________________________
FINISHED CONTRACT
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
YES ✘ NO
Barangay election)? N/A
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: 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? N/A
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
SHYNE P. NOVELO CAINGIN,MARAGONDON,CAVITE 9169606733 3.5 cm. X 4.5 cm
(passport size)
ABIGAIL D. VILAN BUCAL 3A,MARAGONDON,CAVITE 9653681137 With full and handwritten
name tag and signature over
printed name
ANGELA MARY B. ARCIAGA TANZA,CAVITE 9291821033
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: PRC LICENSE
ID/License/Passport No.: 1985609 Signature (Sign inside the box)
JUNE 05,2023
Date/Place of Issuance: 03/10/2023 MANILA Date Accomplished Right Thumbmark
SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.
VIVENCIO G. MATILLA
BARANGAY CAPTAIN
Person Administering Oath
CS FORM 212 (Revised 2017), Page 4 of 4
