CS Form No.

212

PERSONAL DATA SHEET

Revised 2017

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 SIMON
NAME EXTENSION (JR., SR) N/A
FIRST NAME DONALD

MIDDLE NAME GARCIA

3. DATE OF BIRTH
(mm/dd/yyyy)
04/26/1994 16. CITIZENSHIP Filipino Dual Citizenship
by birth by naturalization

4. PLACE OF BIRTH SAN JOSE CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female

Single Married 17. RESIDENTIAL ADDRESS 30 ZONE 1

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
N/A CULAYLAY
Other/s:
Subdivision/Village Barangay
SAN JOSE CITY NUEVA ECIJA
7. HEIGHT (m) 1.66
City/Municipality Province
8. WEIGHT (kg) 85 ZIP CODE 3121

18. PERMANENT ADDRESS 30 ZONE 1

9. BLOOD TYPE A+
House/Block/Lot No. Street
N/A CULAYLAY
10. GSIS ID NO. 2005401246
Subdivision/Village Barangay
SAN JOSE CITY NUEVA ECIJA
11. PAG-IBIG ID NO. 121147787284
City/Municipality Province

12. PHILHEALTH NO. 210502020204 ZIP CODE 3121

13. SSS NO. N/A 19. TELEPHONE NO. N/A

14. TIN NO. 469-506-316-000 20. MOBILE NO. 09684608720

15. AGENCY EMPLOYEE NO. 5381661 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 N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME SIMON

NAME EXTENSION (JR., SR)
FIRST NAME DANILO

MIDDLE NAME DE GUIA

25. MOTHER'S MAIDEN NAME

SURNAME GARCIA

FIRST NAME IMELDA

MIDDLE NAME VIERNES (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

SCHOLARSHIP/
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE HIGHEST LEVEL/
YEAR ACADEMIC
LEVEL UNITS EARNED
(Write in full) (Write in full) (if not graduated)
GRADUATED HONORS
From To RECEIVED

VALEDICTO
ELEMENTARY CULAYLAY ELEMENTARY SCHOOL ELEMENTARY EDUCATION 2001 2006 Graduated 2006
RIAN

SECONDARY CONSTANCIO PADILLA NATIONAL HIGH SCHOOL HIGH SCHOOL 2006 2010 Graduated 2010 N/A

VOCATIONAL /
TRADE COURSE
N/A N/A N/A N/A N/A N/A N/A

BACHELOR OF SCIENCE IN INFORMATION

COLLEGE CENTRAL LUZON STATE UNIVERSITY
TECHNOLOGY
2010 2015 Graduated 2015 N/A

18 PROFESSIONAL
EDUCATION UNITS
CORE GATEWAY COLLEGE INC. PROFESSIONAL EDUCATION UNITS 2016 2016 18 units N/A N/A

GRADUATE STUDIES CORE GATEWAY COLLEGE INC. MASTER OF ARTS IN EDUCATION 2018 2020 Graduated 2020 N/A

GRADUATE STUDIES PANGASINAN STATE UNIVERSITY DOCTOR OF EDUCATION 2021 2023 48 units N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE February 1, 2024

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 Date of
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT Validity
GUIDANCE COUNSELOR LICENSURE
76.15% 08/16-17/2023 BAGUIO CENTRAL SCHOOL 004592 04/26/2026
EXAMINATION

LICENSURE EXAMINATION FOR TECHERS 77.00% 03/25/2017 ROSALES NATIONAL HIGH SCHOOL 1553735 04/26/2027

(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.
INCLUSIVE DATES SALARY/ JOB/ PAY
28. GOV'T
GRADE (if
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY STATUS OF
applicable)& STEP SERVICE
(Write in full/Do not abbreviate) (Write in full/Do not abbreviate) SALARY (Format "00-0")/ APPOINTMENT
(Y/ N)
From To INCREMENT

01/01/2024 Present TEACHER III PORAIS NATIONAL HIGH SCHOOL 31,320.00 13-1 PERMANENT Y

01/01/2023 12/31/2023 TEACHER III PORAIS NATIONAL HIGH SCHOOL 31,320.00 13-1 PERMANENT Y

01/01/2022 12/31/2022 TEACHER III PORAIS NATIONAL HIGH SCHOOL 29,798.00 13-1 PERMANENT Y

06/04/2021 12/31/2021 TEACHER I PORAIS NATIONAL HIGH SCHOOL 24,161.00 11-2 PERMANENT Y

01/01/2021 06/03/2021 TEACHER I PORAIS HIGH SCHOOL 23,877.00 11-1 PERMANENT Y

01/01/2020 12/31/2020 TEACHER I PORAIS HIGH SCHOOL 22,376.00 11-1 PERMANENT Y

01/01/2019 12/31/2019 TEACHER I PORAIS HIGH SCHOOL 20,876.00 11-1 PERMANENT Y

06/04/2018 12/31/2018 TEACHER I PORAIS HIGH SCHOOL 20,176.00 11-1 PERMANENT Y

CONTRACTUA
01/01/2018 12/31/2018 TEACHER BETTBIEN HIGH SCHOOL 9,127.00 N/A N
L
CONTRACTUA
01/01/2017 12/31/2026 TEACHER BETTBIEN HIGH SCHOOL 9,127.00 N/A N
L
CONTRACTUA
01/01/2016 12/31/2027 TEACHER BETTBIEN HIGH SCHOOL 8,500.00 N/A N
L
CONTRACTUA
05/04/2015 12/31/2015 TEACHER BETTBIEN HIGH SCHOOL 8,501.00 N/A N
L

(Continue on separate sheet if necessary)

SIGNATURE DATE February 1, 2024

CS FORM 212 (Revised 2017), Page 2 of 4

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29.
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

PARAISO CHILDREN HOUSE OF REFUGE 06/30/2023 06/30/2023 8 Social Work

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED

INCLUSIVE DATES OF Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To
Counseling through the Storm: Integrating CBT Techniques for Trauma Resilience 11/18/2023 11/08/2023 6 Technical MHPro Counseling and Well-being Center Inc.
Information and Communication Technology
08/08/2022 08/11/2022 40 Technical
Virtual In-Service Training for Public School Teachers 3.0 Services - Department of Education
Division Training on Cross Curriculum Integration Assessment for Senior High School
12/13/2021 12/17/2021 20 Technical Division of San Jose City
Teachers
Division of San Jose City/ Division of Tarlac
Onto Assessment in the New Normal 11/24/2021 11/26/2021 24 Technical
Province
UP Diliman and SDO San Jose City Partnerhip on Content and Pedagogy in Handling
Edukasiyon sa Pagpapakatao, Araling Panlipunan and HUMSS Subject for JHS and SHS 09/02/2021 10/20/2021 28 Technical Division of San Jose City/UP Diliman
Learners
Institute of Physical Education - Nueva Ecija
Sports Education: Understanding and Addressing the Challenges of Pandemic 08/03/2021 08/05/2021 24 Technical
University of Science and Technology
Information and Communication Technology
Virtual In-Service Training for Public School Teachers 03/15/2021 03/19/2021 40 Technical
Services - Department of Education

Division Webinar on Video Lesson Making 08/26/2020 08/28/2020 24 Technical Division of San Jose City

Webinar Session and Simulation of Delivering Learning in Different Modalities in Araling

06/26/2020 06/26/2020 3 Technical Division of San Jose City
Panlipunan
Division Webinar Skills Training for EPP/TLE/TVL Teachers (Face Mask, Face Shield,
06/19/2020 06/19/2020 2 Technical Division of San Jose City
Cookery and Nutriban Making)

Orientation Webinar on IPCRF Data Collection System for SY 2019-2020 06/09/2020 06/09/2020 1 Technical Division of San Jose City

Division Online Training on CORE IT Skills 05/13/2020 05/15/2020 24 Technical Division of San Jose City

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

Philippine Guidance and Counseling

PROGRAMMING Certificate of Recognition - Career Guidance 2021
Association
Certificate of Recognition - Mental Health Awareness

Certificate of Recognition - School Learning Action Cell

(Continue on separate sheet if necessary)

SIGNATURE DATE February 1, 2024

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 NO

b. within the fourth degree (for Local Government Unit - Career Employees)? YES NO
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? 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)? 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
MARK ALVIN M. PRESTO MALIGAYA, SCIENCE CITY OF MUÑOZ 09661355969 4.5 cm. X 3.5 cm
(passport size)

EDMIL C. BIBIS CARIDAD SUR, LLANERA 09456059754

Computer generated
or photocopied picture
ROGELIO S. BALTAZAR PALESTINA, SAN JOSE CITY 09776897690 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

ID/License/Passport No.: 1553735

Signature (Sign inside the box)
February 1, 2024
Date/Place of Issuance: 07/11/2017-BAGUIO 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