CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misinterpretation 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 COMPOC
NAME EXTENSION (JR., SR)
FIRST NAME HAZEL ANNE

MIDDLE NAME ALCALA

3. DATE OF BIRTH
(mm/dd/yyyy) 7/7/1997 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH DASMARINAS, CAVITE 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 1
Widowed House/Block/Lot No. Street
Separated POBLACION 2
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 5'0 Remedios T. Romualdez Agusan del Norte
City/Municipality Province
8. WEIGHT (kg) 51 kg ZIP CODE 8611
18. PERMANENT ADDRESS PUROK 1
9. BLOOD TYPE N/A
House/Block/Lot No. Street

10. GSIS ID NO. N/A Poblacion 2

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121301893144 Remedios T. Romualdez Agusan del Norte

City/Municipality Province

12. PHILHEALTH NO. 18-251518837-2 ZIP CODE 8611

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

14. TIN NO. 776 489 839 000 20. MOBILE NO. 09486488547

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) N/A

FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME COMPOC

FIRST NAME RENATO

MIDDLE NAME MACOMPAL

25. MOTHER'S MAIDEN NAME

SURNAME ALCALA

FIRST NAME FRANCES

MIDDLE NAME NAKILA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

26. NAME OF SCHOOL PERIOD OF ATTENDANCE HIGHEST LEVEL/

YEAR SCHOLARSHIP/
BASIC EDUCATION/DEGREE/COURSE UNITS
LEVEL (Write in EARNED
GRADUATED ACADEMIC
(Write in full) HONORS RECEIVED
full) (if not graduated)
From To

ELEMENTARY AGAY CENTRAL ELEMENTARY SCHOOL ELEMENTARY GRADUATE 2008 2009 GRADUATED 2009 NONE
SECONDARY AGAY NATIONAL HIGH SCHOOL HIGH SCHOOL GRADUATE 2012 2013 GRADUATED 2013 NONE
VOCATIONAL /

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

TRADE
COURSE
BACHELOR OF SECONDARY
COLLEGE NORTHERN MINDANAO COLLEGES INC.
EDUCATION
2019 2020 GRADUATED 2020 NONE

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

(Continue on separate sheet if necessary)

SIGNATURE DATE 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 90.80% OCTOBER 2, 2022 BUTUAN CITY 2118796 7/7/2026

(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)
12/04/2023 01/16/2024 SHIFT SUPERVISOR MUNICIPAL LOCAL GOVERNMENT OF LAS NIEVES 15,886.00 N/A COSW Y

10/16/2023 11/30/2023 SHIFT SUPERVISOR MUNICIPAL LOCAL GOVERNMENT OF BUENAVISTA 10,140.00 N/A COSW Y

PHILIPPINE STATISTICS AUTHORITY - AGUSAN DEL

08/16/2023 10/15/2023 SHIFT SUPERVISOR 15,886.00 N/A COSW Y
NORTE

PHILIPPINE STATISTICS AUTHORITY - AGUSAN DEL

08/07/2023 08/15/2023 CBMS DATA PROCESSOR 4,408.00 N/A COSW Y
NORTE
PHILIPPINE STATISTICS AUTHORITY - AGUSAN DEL
07/05/2023 07/22/2023 ENUMERATOR 9,776.00 N/A COSW Y
NORTE
PHILIPPINE STATISTICS AUTHORITY - AGUSAN DEL
11/30/2022 06/30/2023 DATA PROCESSOR 14, 126.00 N/A COSW Y
NORTE
PHILIPPINE STATISTICS AUTHORITY - AGUSAN DEL
07/28/2022 10/31/2022 ENUMERATOR 14, 126.00 N/A COSW Y
NORTE

09/15/2020 09/20/2020 ENUMERATOR MUNICIPALITY OF REMEDIOS T. ROMUALDEZ 3,200.00 N/A JOB ORDER Y

(Continue on separate sheet if necessary)

SIGNATURE DATE 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

(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) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To
PHILIPPINE STATISTICS AUTHORITY - AGUSAN DEL
COMMUNITY-BASED MONITORING SYSTEM DATA PROCESSOR TRAINING 11/15/2022 11/18/2022 32
NORTE
PHILIPPINE STATISTICS AUTHORITY - AGUSAN DEL
COMMUNITY-BASED MONITORING SYSTEM 2022 TRAINING 07/28/2022 05/08/2022 64
NORTE

COOKERY NC2 10/05/2019 08/21/2019 250 TESDA-PROVINCIAL TRAINING CENTER- CABADBARAN

(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
(Write in full)
in full)

COOKING N/A N/A

ENCODING N/A N/A

 (Continue on separate sheet if necessary)

SIGNATURE DATE 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:
________________________________

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
LORDJAYSSON LEE F. ANTONIO REMEDIOS T. ROMUALDEZ 09072133867 3.5 cm. X 4.5 cm
(passport size)

ADEZA MARIE B. BENEGILDO CABADBARAN CITY 09388909861 With full and handwritten
name tag and signature over
printed name
MARINA R. CASTRO REMEDIOS T. ROMUALDEZ 09383858168
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete or photocopied picture
is not acceptable
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 PHOTO
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 LICENSE

ID/License/Passport No.: 2118796

Signature (Sign inside the box)
Date/Place of Issuance: 10/17/2023
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