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 NUEVA ESPAÑA

NAME EXTENSION (JR., SR) N/A
FIRST NAME LOREN GRACE

MIDDLE NAME ABALLE

3. DATE OF BIRTH
(mm/dd/yyyy) 09/09/1992 16. CITIZENSHIP FILIPINO

4. PLACE OF BIRTH DAVAO CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX FEMALE N/A
17. RESIDENTIAL ADDRESS BLOCK 29 LOT 12 N/A
6 CIVIL STATUS SINGLE House/Block/Lot No. Street

NHA BUHANGIN
Subdivision/Village Barangay

DAVAO CITY DAVAO DEL SUR

7. HEIGHT (m) 1.55m
City/Municipality Province

8. WEIGHT (kg) 51kg ZIP CODE 8000

18. PERMANENT ADDRESS BLOCK 29 LOT 12 N/A
9. BLOOD TYPE A+
House/Block/Lot No. Street

NHA BUHANGIN
10. GSIS ID NO. N/A Subdivision/Village Barangay

DAVAO CITY DAVAO DEL SUR

11. PAG-IBIG ID NO. N/A
City/Municipality Province

12. PHILHEALTH NO. 16-250543041-7 ZIP CODE 8000

13. SSS NO. 09-3390313-5 19. TELEPHONE NO. 327-8463

14. TIN NO. 350-990-054-000 20. MOBILE NO. 09051845030

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 NUEVA ESPAÑA

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

MIDDLE NAME BONGOSIA

25. MOTHER'S MAIDEN NAME ABALLE, LORNA PANERIO

SURNAME ABALLE
FIRST NAME LORNA
MIDDLE NAME PANERIO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE HIGHEST LEVEL/ YEAR SCHOLARSHIP/ ACADEMIC
LEVEL UNITS EARNED GRADUATED HONORS RECEIVED
(Write in full) (Write in full) (if not graduated)
From To
2ND HONORABLE
MENTION AND
ELEMENTARY DAVAO JONES ACADEMY PRIMARY EDUCATION 2001 2005 N/A 2005 PERFECT
ATTENDANCE
WITH HONORS AND
UNIVERSITY OF THE IMMACULATE
SECONDARY HIGH SCHOOL 2005 2009 N/A 2009 DEPORTMENT
CONCEPTION AWARD
VOCATIONAL /
TRADE COURSE N/A N/A N/A N/A N/A N/A N/A
BS BIOLOGY 2009 2011 94 UNITS
COLLEGE ATENEO DE DAVAO UNIVERSITY N/A
AB PSYCHOLOGY 2011 2015 2015
GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE 12/19/2018

CS FORM 212 (Revised 2017), Page 1 of 4

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IV. CIVIL SERVICE ELIGIBILITY

27. LICENSE (if applicable)

CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity

DANIEL R. AGUINALDO NATIONAL HIGH SCHOOL,

CAREER SERVICE PROFESSIONAL 81.14% 10/18/2015 2011151007221801 N/A
MATINA, DAVAO CITY

10/29/2017 & JOSE MARIA COLLEGE, PHIL-JAP FRIENDSHIP HIGHWAY,

REGISTERED PSYCHOMETRICIAN 76.20% 0012191 09/09/2020
10/30/2017 SASA, DAVAO CITY

(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 (mm/dd/

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

From To

ADMINISTRATIVE OFFICE 3LRSJ TRUCKING SERVICES

2015 2018
ASSISTANT (FAMILY BUSINESS)
CLERK-SUPPORTING STAFF OFFICE OF THE OMBUDSMAN FOR
2018 PRESENT
(AGENCY) MINDANAO

(Continue on separate sheet if necessary)

SIGNATURE DATE 12/19/2018

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

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

From To

PROCTOR/ ROOM WATCHER (FACILITATES AND OFFICIATES

PROFESSIONAL REGULATION COMMISSION – Davao Regional Office XI /
LICENSURE EXAMINATION AND SEES TO IT THAT EXAMINEES
Calamansi St. cor. First St. (beside the Indonesian Consulate) Juna Subdivision, 11/17/2018 11/19/2018 18 HOURS
FOLLOWS APPROPRIATE PROTOCOLS AND REGULATIONS DURING
Matina, Davao City
EXAMINATIONS)
PROCTOR/ ROOM WATCHER (FACILITATES AND OFFICIATES
PROFESSIONAL REGULATION COMMISSION – Davao Regional Office XI /
LICENSURE EXAMINATION AND SEES TO IT THAT EXAMINEES
Calamansi St. cor. First St. (beside the Indonesian Consulate) Juna Subdivision, 09/30/2018 09/30/2018 8 HOURS
FOLLOWS APPROPRIATE PROTOCOLS AND REGULATIONS DURING
Matina, Davao City
EXAMINATIONS)
PROCTOR/ ROOM WATCHER (FACILITATES AND OFFICIATES
PROFESSIONAL REGULATION COMMISSION – Davao Regional Office XI /
LICENSURE EXAMINATION AND SEES TO IT THAT EXAMINEES
Calamansi St. cor. First St. (beside the Indonesian Consulate) Juna Subdivision, 03/25/2018 03/25/2018 12 HOURS
FOLLOWS APPROPRIATE PROTOCOLS AND REGULATIONS DURING
Matina, Davao City
EXAMINATIONS)
PROCTOR/ ROOM WATCHER (FACILITATES AND OFFICIATES
PROFESSIONAL REGULATION COMMISSION – Davao Regional Office XI /
LICENSURE EXAMINATION AND SEES TO IT THAT EXAMINEES
Calamansi St. cor. First St. (beside the Indonesian Consulate) Juna Subdivision, 09/24/2017 09/24/2017 12 HOURS
FOLLOWS APPROPRIATE PROTOCOLS AND REGULATIONS DURING
Matina, Davao City
EXAMINATIONS)
PROCTOR/ ROOM WATCHER (FACILITATES AND OFFICIATES
PROFESSIONAL REGULATION COMMISSION – Davao Regional Office XI /
LICENSURE EXAMINATION AND SEES TO IT THAT EXAMINEES
Calamansi St. cor. First St. (beside the Indonesian Consulate) Juna Subdivision, 09/25/2016 09/25/2016 12 HOURS
FOLLOWS APPROPRIATE PROTOCOLS AND REGULATIONS DURING
Matina, Davao City
EXAMINATIONS)
PROCTOR/ ROOM WATCHER (FACILITATES AND OFFICIATES
PROFESSIONAL REGULATION COMMISSION – Davao Regional Office XI /
LICENSURE EXAMINATION AND SEES TO IT THAT EXAMINEES
Calamansi St. cor. First St. (beside the Indonesian Consulate) Juna Subdivision, 03/20/2016 03/20/2016 12 HOURS
FOLLOWS APPROPRIATE PROTOCOLS AND REGULATIONS DURING
Matina, Davao City
EXAMINATIONS)
PROCTOR/ ROOM WATCHER (FACILITATES AND OFFICIATES
PROFESSIONAL REGULATION COMMISSION – Davao Regional Office XI /
LICENSURE EXAMINATION AND SEES TO IT THAT EXAMINEES
Calamansi St. cor. First St. (beside the Indonesian Consulate) Juna Subdivision, 09/27/2015 09/27/2015 12 HOURS
FOLLOWS APPROPRIATE PROTOCOLS AND REGULATIONS DURING
Matina, Davao City
EXAMINATIONS)
(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. ( Managerial/
TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS (Write in full) (mm/dd/yyyy) NUMBER OF HOURS CONDUCTED/ SPONSORED BY (Write in full)
Supervisory/
Technical/etc)
From To

4TH PAP PROFESSIONAL SUMMIT 08/31/2018 09/01/2018 18 HOURS N/A PSYCHOLOGICAL ASSOCIATION OF THE PHILIPPINES

(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)

PROFICIENT COMPUTER SKILLS IN USING

MEMBER OF PSYCHOLOGICAL ASSOCIATION OF THE
MS OFFICE WORD, EXCEL AND N/A
PHILIPPINES (PAP)
POWERPOINT

COMMUNICATION SKILLS (ENGLISH, MEMBER OF ATENEO DE DAVAO UNIVERSITY BLUE

TAGALOG AND VISAYAN) KNIGHT ALUMNI ASSOCIATION, INC.

SOCIAL MEDIA SKILLS (E-MAIL, FACEBOOK,

INSTAGRAM, TWITTER AND YOUTUBE)

PERSONAL SKILLS (DETERMINED,

FLEXIBLE, HONEST, OPEN-MINDED AND
RESOURCEFUL)

MULTI-TASKING SKILLS

TRAVELING

DRAWING

(Continue on separate sheet if necessary)

SIGNATURE DATE 12/19/2018

CS FORM 212 (Revised 2017), Page 3 of 4

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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? NO

b. within the fourth degree (for Local Government Unit - Career Employees)? NO
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:
Status of Case/s:

36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or NO
tribunal?
If YES, give details: ________________________________
________________________________

37. Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped NO
from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in the public or private If YES, give details: ________________________________
sector? ________________________________

38. a. Have you ever been a candidate in a national or local election held within the last year (except Barangay NO
election)?
If YES, give details:

b. Have you resigned from the government service during the three (3)-month period before the last election to NO
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? 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? NO

If YES, please specify:
b. Are you a person with disability? NO
If YES, please specify ID No:
c. Are you a solo parent? 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
3.5 cm. X 4.5 cm
LIBRADA NICOR PAMA WOODRIDGE, MAA, DAVAO CITY 09224581137 (passport size)

With full and handwritten

name tag and signature over
printed name
AURORA INGENTE LAGRAMA DAVAO CITY 09322675432
Computer generated
or photocopied picture
is not acceptable
EVELYN P. VALERIO BUHANGIN PROPER, DAVAO CITY +639198607283
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 administrative/criminal case/s against me. PHOTO

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of Issuance
Government Issued ID: PASSPORT
ID/License/Passport No.: EC5276255 Signature (Sign inside the box)

Date/Place of Issuance: SEPTEMBER 10, 2015 / DFA DAVAO DECEMBER 19, 2018
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

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