EDITED Pdsrev2005

CS FORM 212 (Revised 2005)
PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes
with "
1. CS ID No.
" and use separate sheet if necessary.
(to be filled up by CSC)
I. PERSONAL INFORMATION
E| S | T | A | N |
2. SURNAME
M| A |
FIRST NAME
| E | L | E| N | A |
V| I | L | L | A | R| I | N |
MIDDLE NAME
12 /25 / 1970
4. DATE OF BIRTH (mm/dd/yyyy)

5. PLACE OF BIRTH
6. SEX
7. CIVIL STATUS
Widowed
Separated
Annulled
Others, specify ___________ 18. PERMANENT ADDRESS
FILIPINO
1.14 METERS
10. WEIGHT (kg)
56
3. NAME EXTENSION (e.g. Jr., Sr.)
LANGTAD, CITY OF NAGA, CEBU
Single
9. HEIGHT (m)
Female
Married
8. CITIZENSHIP
16. RESIDENTIAL ADDRESS
NAGA, CEBU
Male
ZIP CODE
6037
489-6883
17. TELEPHONE NO.
LANGTAD, CITY OF NAGA, CEBU
ZIP CODE
6037
11. BLOOD TYPE
" O+ "
19. TELEPHONE NO.
489-6883
12. GSIS ID NO.
2002690794
20. E-MAIL ADDRESS (if any)
[email protected]
13. PAG-IBIG ID NO.
1640-0160-8931
21. CELLPHONE NO. (if any)
09096075602
14. PHILHEALTH NO.
151722000005
22. AGENCY EMPLOYEE NO.
413 4114
15. SSS NO.
NONE
23. TIN
215 290 811
II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME
25. NAME OF CHILD (Write full name and list all)
ESTAN
DATE OF BIRTH (mm/dd/yyyy)
FIRST NAMENOEL
MARK ANTHONY VILLARIN ESTAN
04/17/1997
MIDDLE NA
MARIAN VILLARIN ESTAN
06/05/2004
LONGAKIT
OCCUPATION
INSULATOR
EMPLOYER/BUS. NAME
BRILLIANT METAL CRAFT
BUSINESS ADDRESS
MABOLO, CEBU CITY
TELEPHONE NO.
233-5927
(Continue on separate sheet if necessary)
/
/
VILLARIN
FIRST NAME
FELIX SR.
MIDDLE NAME
ALBISO
26. FATHER'S SURNAME
27. MOTHER'S MAIDEN NAME

SURNAME
LAPIZ
FIRST NAME
FEDILA
MIDDLE NAME
CANOY
III. EDUCATIONAL BACKGROUND

28.
YEAR
GRADUATED
NAME OF SCHOOL
LEVEL
(Write in
DEGREE COURSE
(Write in full)
full)
ELEMENTARY
CABUNGAHAN ELEMENTARY SCHOOL
SECONDARY
VOCATIONAL /
LANTAD BARANGAY HIGH SCHOOL
(if
graduated)
HIGHEST GRADE/
LEVEL/
UNITS EARNED
(if not graduated)
INCLUSIVE DATES OF
ATTENDANCE
SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED
From
To
SECOND HONOR
1984
GRADUATED
JUNE 1979
MARCH
1984
1988
GRADUATED
JUNE 1984
MARCH
1988
SEVENTH HONOR
1997
GRADUATED
JUNE 1992
OCTOBER
1997
NONE
NONE
COLLEGE
TRADE
COURSE
UNIVERSITY OF THE VISAYAS
BACHELOR OF
SCIENCE IN
ELEMENTARY
EDUCATION
GRADUATE STUDIES
NONE

Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY

29.
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER

SPECIAL LAWS/ CES/ CSEE
RATING
LICENSURE EXAMINATION FOR TEACHERS
DATE OF
EXAMINATION /
CONFERMENT
08/01/1998
LICENSE (if applicable)

PLACE OF EXAMINATION / CONFERMENT
CEBU CITY
NUMBER
0497513
DATE OF
RELEASE
11/18/1998
V. WORK EXPERIENCE (Include private employment. Start from your current work)
INCLUSIVE DATES
(mm/dd/yyyy)
30.
From
POSITION TITLE
DEPARTMENT / AGENCY / OFFICE / COMPANY

(Write in full)
To
(Write in full)
GOV'T
SERVICE
MONTHLY
SALARY
SALARY GRADE
& STEP
INCREMENT
(Format "00-0")
STATUS OF
APPOINTMENT
(Yes /
No)
06/02/2012
10/03/2013
TEACHER - II
DEPARTMENT OF EDUCATION
LANGTAD ELEMENTARY SCHOOL
06/01/2012
06/01/2012
TEACHER - II
20,341
12-3
REGULAR
PERMANENT
YES
06/01/2011
05/31/2012
TEACHER - II
18,805
11-3
REGULAR
PERMANENT
YES
06/24/2010
05/31/2011
TEACHER - II
17,269
11-3
REGULAR
PERMANENT
YES
07/01/2009
06/23/2010
TEACHER - II
15,733
11-3
REGULAR
PERMANENT
YES
06/02/2009
06/30/2009
TEACHER - II
13,392
11-3
REGULAR
PERMANENT
YES
07/01/2008
06/01/2009
TEACHER - II
13,066
11-2
REGULAR
PERMANENT
YES
07/01/2007
01/30/2008
TEACHER - II
11,878
11-2
REGULAR
PERMANENT
YES
06/02/2006
06/30/2007
TEACHER - II
10,798
11-2
REGULAR
PERMANENT
YES
06/02/2003
06/01/2006
TEACHER - II
10,535
10-2
REGULAR
PERMANENT
YES
11/28/2001
06/01/2003
TEACHER - II
9,939
10-1
REGULAR
PERMANENT
YES
08/07/2001
11/27/2001
TEACHER - II
9,939
10-1
REGULAR
PERMANENT
YES
08/08/2000
06/30/2001
TEACHER - II
4,000
10-1
REGULAR
PERMANENT
YES
06/06/2000
08/05/2000
TEACHER - II
9,466
10-1
REGULAR
PERMANENT
YES
01/03/2000
03/02/2000
TEACHER - II
9,466
10-1
REGULAR
PERMANENT
YES
10/26/1999
12/24/1999
TEACHER - II
9,466
10-1
REGULAR
PERMANENT
YES
20,545
12-4
REGULAR
PERMANENT
YES

CS FORM 212 (Revised 2005), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

INCLUSIVE DATES
31. NAME & ADDRESS OF ORGANIZATION
NUMBER OF
HOURS
(mm/dd/yyyy)
(Write in full)
From
NONE
POSITION / NATURE OF WORK
To
VII. TRAINING PROGRAMS (Start from the most recent training.)

INCLUSIVE DATES OF ATTENDANCE
32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write
in full)
FOUR-DAY MID-YEAR ASSESTMENT AND IN SERVICE

TRAINING FOR TEACHERS
NUMBER OF
HOURS
(mm/dd/yyyy)
From
To
10/20/2012
10/25/2012
32
CONDUCTED/ SPONSORED BY
(Write in full)
CEPOC CENTRAL SCHOOL
VIII. OTHER INFORMATION

33.
SPECIAL SKILLS / HOBBIES:
34.
NON-ACADEMIC DISTINCTIONS / RECOGNITION:

(Write in full)
35.
MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(Write in full)
NONE
NONE
NONE

36. Are you related by consanguinity or affinity to any of the following :

a. Within the third degree (for National Government Employees):
appointing authority, recommending authority, chief of office/bureau/department or person who

has immediate supervision over you in the Office, Bureau or Department where you will be
appointed?
b. Within the fourth degree (for Local Government Employees):
appointing authority or recommending authority where you will be appointed?
37 a. Have you ever been formally charged?
YES
NO
If YES, give details:
_____________________________________
_____________________________________
_____________________________________
YES
NO
_____________________________________
_____________________________________
_____________________________________
YES
NO

________________________________
________________________________
YES
b. Have you ever been guilty of any administrative offense?
NO

________________________________
________________________________
38. Have you ever been convicted of any crime or violation of any law, decree, ordinance or
regulation by any court or tribunal?
39. Have you ever been separated from the service in any of the following modes: resignation,
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract, AWOL or
phased out, in the public or private sector?
40. Have you ever been a candidate in a national or local election (except Barangay election)?
YES
NO
________________________________
________________________________
YES
NO

________________________________
________________________________
YES
NO

________________________________
________________________________
41. 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?
b.
Are you differently abled?
c.
Are you a solo parent?
YES
NO
If YES, please specify: ____________________
YES
NO
YES
NO
42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)

NAME
ADDRESS
BACALSO, MARCELO
BASAK, PARDO, CEBU
CHIDING, VALDEMAR
POBLACION, NAGA
LAYASAN, ANA LIZA
LANGTAD, CITY OF NAGA
TEL. NO.
43. I declare under oath
that this Personal Data Sheet has been accomplished by me, and is a true, correct and
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the
Philippines.
I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust
that this information shall remain confidential.
ID picture taken within

the last 6 months
3.5 cm. X 4.5 cm
(passport size)
Computer generated
or xerox copy of picture
is not acceptable
PHOTO
COMMUNITY TAX CERTIFICATE NO.
ISSUED AT
SIGNATURE (Sign inside the box)
ISSUED ON (mm/dd/yyyy)
DATE ACCOMPLISHED
RIGHT THUMBMARK

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CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

" and use separate sheet if necessary.

(to be filled up by CSC)

4. DATE OF BIRTH (mm/dd/yyyy)

Others, specify ___________ 18. PERMANENT ADDRESS

10. WEIGHT (kg)

3. NAME EXTENSION (e.g. Jr., Sr.)

LANGTAD, CITY OF NAGA, CEBU

16. RESIDENTIAL ADDRESS

17. TELEPHONE NO.

LANGTAD, CITY OF NAGA, CEBU

11. BLOOD TYPE

19. TELEPHONE NO.

12. GSIS ID NO.

20. E-MAIL ADDRESS (if any)

13. PAG-IBIG ID NO.

21. CELLPHONE NO. (if any)

14. PHILHEALTH NO.

22. AGENCY EMPLOYEE NO.

15. SSS NO.

215 290 811

II. FAMILY BACKGROUND

25. NAME OF CHILD (Write full name and list all)

DATE OF BIRTH (mm/dd/yyyy)

MARK ANTHONY VILLARIN ESTAN

MARIAN VILLARIN ESTAN

BRILLIANT METAL CRAFT

MABOLO, CEBU CITY

(Continue on separate sheet if necessary)

26. FATHER'S SURNAME

27. MOTHER'S MAIDEN NAME

(Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

CABUNGAHAN ELEMENTARY SCHOOL

LANTAD BARANGAY HIGH SCHOOL

UNIVERSITY OF THE VISAYAS

(Continue on separate sheet if necessary)

IV. CIVIL SERVICE ELIGIBILITY

CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER

LICENSURE EXAMINATION FOR TEACHERS

LICENSE (if applicable)

(Continue on separate sheet if necessary)

DEPARTMENT / AGENCY / OFFICE / COMPANY

(Continue on separate sheet if necessary)

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

(Continue on separate sheet if necessary)

VII. TRAINING PROGRAMS (Start from the most recent training.)

FOUR-DAY MID-YEAR ASSESTMENT AND IN SERVICE

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

SPECIAL SKILLS / HOBBIES:

NON-ACADEMIC DISTINCTIONS / RECOGNITION:

(Continue on separate sheet if necessary)

36. Are you related by consanguinity or affinity to any of the following :

appointing authority, recommending authority, chief of office/bureau/department or person who

b. Within the fourth degree (for Local Government Employees):

appointing authority or recommending authority where you will be appointed?