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 SARMIENTO
NAME EXTENSION (JR., SR)
FIRST NAME EDMAR CIELO

MIDDLE NAME BASALLO

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 12/15/1993 ✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH SANTA ROSA, NUEVA ECIJA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS 211 PUROK 2
Widowed Separated House/Block/Lot No. Street
RIZAL
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 1.55 SANTA ROSA NUEVA ECIJA
City/Municipality Province
8. WEIGHT (kg) 67 ZIP CODE 3101
18. PERMANENT ADDRESS
9. BLOOD TYPE O
House/Block/Lot No. Street

10. GSIS ID NO. N/A

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121171163394

City/Municipality Province

12. PHILHEALTH NO. 210502297621 ZIP CODE

13. SSS NO. 02-4024847-3 19. TELEPHONE NO. N/A

14. TIN NO. 605-668-843 20. MOBILE NO. 09634428407

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)

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 NAME N/A N/A N/A

BUSINESS ADDRESS N/A N/A N/A

TELEPHONE NO. N/A N/A N/A

24. FATHER'S SURNAME SARMIENTO N/A N/A

NAME EXTENSION (JR., SR)
FIRST NAME EDMAR

MIDDLE NAME SANGLAY

25. MOTHER'S MAIDEN NAME

SURNAME BASALLO

FIRST NAME MARIA

MIDDLE NAME (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY E. SAULO MEMORIAL SCHOOL PRIMARY EDUCATION 2000 2006 GRADUATED 2006 N/A

SECONDARY /
VOCATIONAL ST. ROSE OF LIMA CATHOLIC SCHOOL SECONDARY EDUCATION 2006 2010 GRADUATED 2010 N/A

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

TRADE
BACHELOR OF ELEMENTARY
COURSE
COLLEGE PHINMA - ARAULLO UNIVERSITY 2012 2016 GRADUATED 2016 N/A
EDUCATION

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

(Continue on separate sheet if necessary)

SIGNATURE DATE May 18, 2023

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

LICENSURE EXAMINATION FOR TEACHERS 76.80% 03/25/2018 BAGUIO CITY 1632012 12/15/2024

(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
28. INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
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
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)
OFFICE OF THE MUNICIPAL SOCIAL
2/11/2016 12/30/2020 DAY CARE WORKER 5500.00 N/A CONTRACTUAL Y
WELFARE AND DEVELOPMENT
MUNICIPAL LOCAL SCHOOL BOARD-
1/4/2021 present MUNICPAL OF SANTA ROSA 7000.00 N/A CONTRACTUAL Y
TEACHER

(Continue on separate sheet if necessary)

SIGNATURE DATE May 18, 2023

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

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
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) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

BREAD AND PASTRY PRODUCTION 11/27/2018 3/1/2019 189.0 TECHNICAL SKILL- POWER INSTITUTE, INC.

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

COOKING SKILL N/A N/A

DANCING N/A N/A

COMPUTER LITERATE N/A N/A

LEADERSHIP SKILL N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE May 18, 2023

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 ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘

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? ________________________________
________________________________
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
MARIETTA G. BONITE, Ph. D. BRGY. GOMEZ, SANTA ROSA, N.E 09498878973 4.5 cm. X 3.5 cm
(passport size)

ROSALIE CRUZ BRGY. RIZAL, SANTA ROSA, N.E 09975335046

Computer generated
or photocopied picture
ALEXANDER A. SANTOS BRGY. LUNA, SANTA ROSA, N.E 09551523978 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/License/Passport No.: 1632012 Signature (Sign inside the box)
May 18, 2023
Date/Place of Issuance: 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