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 SALAMA
NAME EXTENSION (JR., SR)
FIRST NAME NORHAYNIE

MIDDLE NAME MACABA-AS

3. DATE OF BIRTH
01/17/1982 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH WAO LANAO DEL SUR If holder of dual citizenship, Pls. indicate country:

please indicate the details.

5. SEX Male ✘ Female
6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS PUROK 3 FR. ZAMORA STREET
House/Block/Lot No. Street
Widowe Separated
BRGY. MANILA GROUP
d
Other/s: Subdivision/Village Barangay
WAO LANAO DEL SUR
7. HEIGHT (m) 1.54
City/Municipality Province
8. WEIGHT (kg) 48 ZIP CODE 9716

18. PERMANENT ADDRESS PUROK 3 FR. ZAMORA STREET

9. BLOOD TYPE "O"
House/Block/Lot No. Street
BRGY. MANILA GROUP
10. GSIS ID NO. 006-0178-8181-2
Subdivision/Village Barangay
WAO LANAO DEL SUR
11. PAG-IBIG ID NO. 1211-332-54374
City/Municipality Province

12. PHILHEALTH NO. 20-000012061-7 ZIP CODE 9716

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

14. TIN NO. 950-601-152 20. MOBILE NO. 09109833391

15. AGENCY EMPLOYEE NO. 059-004-3665 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME SALAMA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) SITTIE AZNAIRAH M. SALAMA
FIRST NAME AMER 9/9/2009

MIDDLE NAME TICO NORJANAH M. SALAMA 7/10/2010

OCCUPATION FACTORY WORKER PRINCESS AMERAH M. SALAMA 6/16/2016

EMPLOYER/BUSINESS NAME GENTUNA _ _

BUSINESS ADDRESS GENERAL SANTOS CITY _ _

TELEPHONE NO. N/A _ _

24. FATHER'S SURNAME MACABA-AS _ _

FIRST NAME LUCMAN _ _

MIDDLE NAME ROMIRIC _ _

25. MOTHER'S MAIDEN NAME _ _

SURNAME LORCA _ _

FIRST NAME JOCELYN _ _

MIDDLE NAME LECHUGAS (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY WAO CENTRAL COMMUNITY SCHOOL ELEMENTARY 1987 1995 GRADUATED 1995 2ND HONORABLE
MENTION

VOCATIONAL MINDANAO STATE UNIVERSITY-WAO

SECONDARY /
2ND HONORABLE
COMMUNITY HIGH SCHOOL
HIGH SCHOOL 1994 1999 GRADUATED 1999 MENTION

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

TRADE
COURSE BACHELOR OF SECONDARY EDUCATION
COLLEGE MINDANAO STATE UNIVERSITY-MAIN CAMPUS
MAJOR IN MATHEMATICS
1998 2005 GRADUATED 2005 N/A

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary) DATE 08/28/2019

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
RA 1080 (LICENSURE EXAMINATION FOR
75.0 8/27/2006 CAGAYAN DE ORO CITY 0928277 1/17/2021
TEACHERS)

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(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
SERVICE
28. INCLUSIVE DATES SALARY/ JOB/ PAY
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
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To (Y/
N)
01/01/2018 PRESENT SECONDARY SCHOOL TEACHER 1 DEPARTMENT OF EDUCATION-LANAO DEL SUR 1 P20,437.00 11-2 PERMANENT YES

01/24/2017 12/31/2017 SECONDARY SCHOOL TEACHER 1 DEPARTMENT OF EDUCATION-LANAO DEL SUR 1 P19,852.00 11-2 PERMANENT YES

01/01/2017 01/23/2017 SECONDARY SCHOOL TEACHER 1 DEPARTMENT OF EDUCATION-LANAO DEL SUR 1 P19,852.00 11-2 PERMANENT YES

01/01/2016 12/31/2016 SECONDARY SCHOOL TEACHER 1 DEPARTMENT OF EDUCATION-LANAO DEL SUR 1 P19,286.00 11-2 PERMANENT YES

06/1/2012 12/31/2015 SECONDARY SCHOOL TEACHER 1 DEPARTMENT OF EDUCATION-LANAO DEL SUR 1 P18,549.00 11-1 PERMANENT YES

6/1/2011 5/31/2012 SECONDARY SCHOOL TEACHER 1 DEPARTMENT OF EDUCATION-LANAO DEL SUR 1 P17,099.00 11-1 PERMANENT YES

6/24/2010 5/31/2011 SECONDARY SCHOOL TEACHER 1 DEPARTMENT OF EDUCATION-LANAO DEL SUR 1 P15,649.00 11-1 PERMANENT YES

7/15/2009 6/23/2010 SECONDARY SCHOOL TEACHER 1 DEPARTMENT OF EDUCATION-LANAO DEL SUR 1 P14,198.00 11-1 PERMANENT YES

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(Continue on separate sheet if necessary)

SIGNATURE DATE 08/28/2019

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
YOUNG AMBASSADOR FOR CHRIST ORGANIZATION
4/10/2008 PRESENT PRESIDENT
KATUTUNGAN, WAO, LANAO DEL SUR

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

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

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

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

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

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) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To
MINISTRY OF BASIC, HIGHER AND TECHNICAL
TIME MANAGEMENT 08/03/19 08/03/19 8 HOURS MANAGERIAL
EDUCATION - WAO 1 DISTRICT
DIVISION ROLL-OUT ON THE PHILIPPINE PROFESSIONAL STANDARDS FOR
TEACHERS (PPST) RESOURCE PACKAGE AND RESULTS-BASED PERFORMANCE MINISTRY OF BASIC, HIGHER AND TECHNICAL
06/24/2019 06/25/2019 16 HOURS MANAGERIAL
MANAGEMENT SYSTEM (RPMS) MANUAL FOR TEACHERS AND SCHOOL HEADS EDUCATION- BARMM

TWO-DAY TRAINING - SEMINAR FOR TEACHERS ON " 2017 RULES ON DEPARTMENT OF EDUCATION - AUTONOMOUS REGION IN
11/27/2018 11/28/2018 16 HOURS MANAGERIAL MUSLIM MINDANAO -DIVISION OF LANAO DEL SUR 1
ADMINISTRATIVE CASES IN THE CIVIL SERVICE (2017 RACCS)"

ONE-DAY 2018 DIVISION ORIENTATION OF DIVISION GSP DISTRICT FIELD DEPARTMENT OF EDUCATION - AUTONOMOUS REGION IN
08/09/2018 08/09/2018 8 HOURS MANAGERIAL MUSLIM MINDANAO -DIVISION OF LANAO DEL SUR 1
ADVISERS AND SECONDARY COORDINATORS
DEPARTMENT OF EDUCATION - AUTONOMOUS REGION IN
2ND TRAINING-WORKSHOP ON RESEARCH 11/29/2017 11/30/2017 16 HOURS MANAGERIAL MUSLIM MINDANAO -DIVISION OF LANAO DEL SUR 1

DEPARTMENT OF EDUCATION - AUTONOMOUS REGION IN

2017 REGIONAL SPORTS ACCREDITATION FOR SPORTS OFFICIATING OFFICIALS
02/25/2017 1/3/2017 40 HOURS MANAGERIAL MUSLIM MINDANAO - BUREAU OF PHYSICAL EDUCATION
AND COACHES SPECIAL EVENTS
DEPARTMENT OF EDUCATION - AUTONOMOUS REGION IN
BASIC EDUCATION CURRICULUM (BEC) CLUSTER I MASS TRAINING FOR GRADE
04/29/2013 05/03 2013 48 HOURS MANAGERIAL MUSLIM MINDANAO/ BASIC EDUCATION ASSISTANCE FOR
8 ENGLISH TEACHER MINDANAO

CANDLE MAKING 07/18/2012 07/18/2012 8 HOURS MANAGERIAL TECHNICAL EDUCATION SKILLS AUTHORITY

GIRLS SCOUT OF THE PHILIPPINES WESTERN

UP-DATE TROOP LEADERS, DFA'S AND SECONDARY COORDINATORS 09/25/2012 09/27/2012 24 HOURS MANAGERIAL
MINDANAO DIVISION OF LANAO DEL SUR 1
DEPARTMENT OF EDUCATION - AUTONOMOUS REGION IN
K TO 12 REGIONAL MASS TRAINING OF GRADE 7 TEAACHERS 12/5/2012 05/16/2012 48 HOURS MANAGERIAL MUSLIM MINDANAO/ BASIC EDUCATION ASSISTANCE FOR
MINDANAO
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VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33. (Write
(Write in full)
in full)
PHILIPPINE PUBLIC SCHOOL TEACHERS
DRAWING OUTSTANDING TEACHER DIVISION OF LANAO DEL SUR 1
ASSOCIATION
SINGING _ MSU ALUMNI ASSOCIATION
NATIONAL ASSOCIATION OF
PLAYING GUITAR _
PROFESSIONAL TEACHERS INC.
WAO I PUBLIC SCHOOL TEACHERS
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ASSOCIATION
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(Continue on separate sheet if necessary)

SIGNATURE DATE 08/28/2019
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:
________________________________

a. Have you ever been found guilty of any administrative offense?

35. 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
by any court or tribunal? YES ✘ NO
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? ________________________________
________________________________
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
MRS.SHORAIDA A. ABANTAS-AMPATUA EXTENSION, WAO, LANAO DEL SUR N/A 3.5 cm. X 4.5 cm
(passport size)

MISS SHARIFA A. ABANTAS EXTENSION, WAO, LANAO DEL SUR N/A With full and handwritten
name tag and signature over
MANILA GROUP, WAO, LANAO DEL printed name
MR.RANNEL C. REMOROSA SUR
N/A
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 ID

ID/License/Passport No.: 0928381

Signature (Sign inside the box)

Date/Place of Issuance: 12/11/2006/CAGAYAN DE ORO CITY

08/28/2019
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