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. D1. CS ID N (Do not fill up. For CSC use only)
I. PERSONAL INFORMATION
2. SURNAME VALENCIA
NAME EXTENSION (JR., SR)
FIRST NAME MARICAR

MIDDLE NAME BISUECOS

3. DATE OF BIRTH
(mm/dd/yyyy)
NOVEMBER 18, 2000 16. CITIZENSHIP FILIPINO

4. PLACE OF BIRTH BACULUD AMULUNG CAGAYAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX FEMALE

17. RESIDENTIAL ADDRES #71 CUNTAPAY STREET

6 CIVIL STATUS SINGLE
House/Block/Lot No. Street
ARELLANO EXTENSION UGAC SUR
Subdivision/Village Barangay
7. HEIGHT (m) 1.65 TUGUEGARAO CITY CAGAYAN
City/Municipality Province
8. WEIGHT (kg) 47kg ZIP CODE 3500

18. PERMANENT ADDRES #71 CUNTAPAY STREET

9. BLOOD TYPE N/A
House/Block/Lot No. Street
ARELLANO EXTENSION UGAC SUR
10. GSIS ID NO. N/A
Subdivision/Village Barangay
11. PAG-IBIG ID NO. N/A TUGUEGARAO CITY CAGAYAN
City/Municipality Province

2. PHILHEALTH NO. N/A ZIP CODE 3500

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

14. TIN NO. N/A 20. MOBILE NO 09754575748

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

II. FAMILY BACKGROUND

23. NAME of CHILDREN (Write full name and DATE OF BIRTH
22 SPOUSE'S SURNAME N/A list all) (mm/dd/yyyy)
N/A
FIRST NAME N/A
NAME EXTENSION (JR., SR) N/A
N/A
MIDDLE NAME N/A N/A
N/A
OCCUPATION N/A N/A
N/A
EMPLOYER/BUSINESS NAM N/A N/A
N/A
BUSINESS ADDRESS N/A N/A
N/A
TELEPHONE NO. N/A N/A
N/A
24.ATHER'S SURNAME VALENCIA N/A
N/A
NAME EXTENSION (JR., SR)
FIRST NAME CHRISTOPHER N/A
N/A
MIDDLE NAME VILLAROZA N/A
N/A
25 MOTHER'S MAIDEN NAME N/A
N/A
SURNAME BISUECOS N/A
N/A
FIRST NAME MARITES N/A

MIDDLE NAME CABUDOL (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY BACULUD ELEMENTARY SCHOOL N/A 2006 2013 2013

SECONDARY OUR LADY OF VICTORIES ACADEMY N/A 2013 2017 2017

VOCATIONAL /
TRADE COURSE
UNIVERSITY OF SAINT LOUIS HUMANITIES AND SOCIAL SCIENCES 2017 2019 2019

BACHELOR OF SCIENCE IN LOYALTY

COLLEGE UNIVERSITY OF SAINT LOUIS
PSYCHOLOGY 2019 2024 2024 AWARD

GRADUATE STUDIES SAINT PAUL UNIVERSITY PHILIPPINES MASTER'S OF PSYCHOLOGY 2024 2026
(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 2, 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
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity
B04 06/20/24
DRIVER'S LICENSE N/A JUNE 20, 2024 LTO SAN GABRIEL TUGUEGARAO CITY
-24004293 -11/18/28

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

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

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 2, 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
CAGAYAN VALLEY CENTER FOR HEALTH DEVELOPMENT -DEPARTMENT
07/01/2023 08/01/2023 150.0 INTERN
OF HEALTH
DEPARTMENT OF BEHAVIOURAL MEDICINE - CAGAYAN VALLEY
MEDICAL CENTER 09/01/2023 09/21/2023 100.0 INTERN

OASIS PSYCHOLOGICAL TESTING AND COUNSELLING CENTER 10/15/2023 12/15/2024 150.0 INTERN

BASIC EDUCATION SCHOOL GUIDANCE OFFICE UNIVERSITY OF SAINT

01/30/2024 04/06/2024 300.0 INTERN
LOUIS

(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
PAPJA 37th ANNUAL NATIONAL AND VIRTUAL EVENT: Moving Forward Towards Psychological Association of the Philippines
04/19/2024 04/20/2024 12.0
a Global, Scientific, Ethical, and Socially Relevant Philippine Psychology Junior Affiliates
MASTERING THE MODERN SUPPLY CHAIN: BEST PRACTICES AND INNOVATION
07/29/2023 07/29/2023 4.0
Polytechnic University of the Philippines
PAPJA 36th ANNUAL NATIONAL AND VIRTUAL EVENT: Framing Climate Change Psychological Association of the Philippines
03/24/2023 03/25/2023 16.0
for Global Mental Health Junior Affiliates

(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)

JUNIOR ASSOCIATION OF PSYCHOLOGY

CAN WORK UNDER PRESSURE LOYALTY AWARD
STUDENTS
Effective in Interpersonal Skills,
Communication Skills, and Teamwork
Proactive approach Skill
to tasks and problem-
solving
Computer proficiency (Microsoft Word,
PowerPoint, and Excel)
Fast Learner and can work harmoniously
with others
Openness to new tools and technologies,
Organized and detail orientated

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 2, 2024

CS FORM 212 (Revised 2017), Page 3 of 4
34. Are you related by consanguinity or affinity to the appointing or recommending
chief of bureau or office or to the person who has immediate supervision over NO
Bureau or Department where you will be apppointed,
a. within the third degree?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:

35. a. Have you ever been found guilty of any administrative offense? NO
If YES, give details:

b. Have you been criminally charged before any court? NO

If YES, give details:
Date Filed:
tatus of Case/s:
36. Have you ever been convicted of any crime or violation of any law, decree, NO
ordinance or regulation by any court or tribunal?
If YES, give details:

37. Have you ever been separated from the service in any of the following modes: NO
resignation, retirement, dropped from the rolls, dismissal, termination, end of If YES, give details:
term, finished contract or phased 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 NO
last year (except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month NO
period before the last election to promote/actively campaign for a national or If YES, give details:
local candidate?
39. Have you acquired the status of an immigrant or permanent resident of another NO
country?
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) NO
a. please
Are you aanswer
member theoffollowing items: group?
any indigenous
If YES, please specify:
b. Are you a person with disability?
If YES, please specify ID No:
c. Are you a solo parent?
If YES, please specify ID No:

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

ID picture taken within
NAME ADDRESS TEL. NO. the last 6 months
4.5 cm. X 3.5 cm
EVANGELINE E. FAJARDO, RPSy, DPA Tuguegarao City 0927-459-2789 (passport size)

Computer generated
JAYCEE M. DEZA Allacapan, Cagayan 0905-243-7534 or photocopied picture
is not acceptable

JADE MICHELLE C. PABALINAS, Rpm Lallo, Cagayan 0997-073-0918

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 PHOTO
misrepresentation made in this document and its attachments shall cause the filing of
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: DRIVER'S LICENSE

ID/License/Passport No.B04-24-004293
Signature (Sign inside the box)

Date/Place of Issuance: JUNE 20, 2024

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

Yes/No Cstat Gender
Yes Single Male
No Married Female
Separated
Widowed