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 QUIBUYEN
NAME EXTENSION (JR., SR)
FIRST NAME GLYZLE GWEEN

MIDDLE NAME BALDONADO

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 6/11/1993 ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH LUTAYAN,SULTAN KUDARAT If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS BLK 9, LOT 26

House/Block/Lot No. Street
Widowed Separated
AGREDA PHASE 2 STO. NIÑO
Other/s:
Subdivision/Village Barangay
KORONADAL CITY SOUTH COTABATO
7. HEIGHT (m) 5'6
City/Municipality Province
8. WEIGHT (kg) 79 kgs. ZIP CODE 9506
18. PERMANENT ADDRESS
9. BLOOD TYPE +A
House/Block/Lot No. Street
PRK. DAISY TAMNAG
10. GSIS ID NO.
Subdivision/Village Barangay
LUTAYAN SULTAN KUDARAT
11. PAG-IBIG ID NO. 1211-1933-3849
City/Municipality Province
12. PHILHEALTH NO. 17-025472067-7 ZIP CODE 9803

13. SSS NO. 09-3751678-0 19. TELEPHONE NO. 083-520-0060

14. TIN NO. 454-720-940 20. MOBILE NO. 0905-112-1099

15. AGENCY EMPLOYEE NO. 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 N/A N/A

MIDDLE NAME

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME QUIBUYEN

FIRST NAME CRISANTO JR.

MIDDLE NAME DE LEON

25. MOTHER'S MAIDEN NAME

SURNAME BALDONADO

FIRST NAME ANNALYN

MIDDLE NAME MEDINA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

KORONADAL CENTRAL ELEMENTARY

ELEMENTARY
SCHOOL-1
PRIMARY EDUCATION 2005 2006 N/A 2006 GRADUATE

VOCATIONAL
SECONDARY / KING'S COLLEGE OF MARBEL, INC. HIGH SCHOOL 2006 2010 N/A 2010 GRADUATE

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

TRADE
COURSE DEAN'S
COLLEGE ST. ALEXIUS COLLEGE BSIT 2010 2014 N/A 2014 LISTER

GRADUATE STUDIES ATENEO DE DAVAO UNIVERSITY MPA 2021 PRESENT

(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
MARBEL INSTITUTE OF TECHNICAL 13120102005
NC2 COMPUTER HARDWARE SERVICES 10/18/2013 10/18/2013
COLLEGE INC. 757
SOUTHERN INSTITUTE OF TECHNICAL 19126302006
NC2 COMPUTER SYSTEMS SERVICING 10/18/2019
EDUCATION & DRIVING SCHOOL, INC.
10/18/2019
585

(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
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
MONTHLY STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To
(Y/ N)

1/3/2021 PRESENT CLERK I PROVINCIAL GOVERNORS OFFICE 11,761 619 REGULAR CASUAL Y

1/1/2016 1/3/2021 LABORER 1 PROVINCIAL GOVERNORS OFFICE 6900.00 350 J.O Y

07/17/2014 12/31/2015 MEDICAL RECORDS STAFF DR. ARTURO P. PINGOY MEDICAL CENTER 7400.00 300 PERMANENT N

5/6/2013 10/30/2013 I.T DR. ARTURO P. PINGOY MEDICAL CENTER OJT N

1/1/2012 03/30/2013 ASSISTANT INSTRUCTOR -COMPTECH ST. ALEXIUS COLLEGE INC. 2100.00 350 PART-TIME N

(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
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (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
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) From To Technical/etc)

COMPUTER SYSTEM SERVICING NC2 06/22/2019 09/13/2019 280 TECHNICAL SITE/TESDA

OCCUPATIONAL HEALTH AND SAFETY LECTURE 02/19/2016 02/19/2016 6 TECHNICAL DR. ARTURO P. PINGOY MEDICAL CENTER

DAPPMC ANNUAL GENERAL ASSEMBLY 01/15/2015 01/16/2015 24 TECHNICAL DR. ARTURO P. PINGOY MEDICAL CENTER

CUSTOMER SERVICE-HANDLING COMPLAINTS 02/18/2015 02/20/2015 36 TECHNICAL DR. ARTURO P. PINGOY MEDICAL CENTER

OCCUPATIONAL HEALTH AND SAFETY- TB, HIV, HEPATITIS & SMOKING

CESSATION 02/26/2015 02/27/2015 24 TECHNICAL DR. ARTURO P. PINGOY MEDICAL CENTER

PATIENT SAFETY 03/19/2015 03/20/2015 24 TECHNICAL DR. ARTURO P. PINGOY MEDICAL CENTER

BASIC LIFE SUPPORT TRAINING 03/26/2015 03/27/2015 24 TECHNICAL DR. ARTURO P. PINGOY MEDICAL CENTER

DISASTER MANAGEMENT: BOMB THREAT AWARENESS AND FIRE SAFETY

TRAINING & INTERNAL DISASTER PREPAREDNESS 05/14/2015 05/15/2015 24 TECHNICAL DR. ARTURO P. PINGOY MEDICAL CENTER

ORIENTATION OF NEW HIRES 7/8/2014 7/8/2014 4 TECHNICAL DR. ARTURO P. PINGOY MEDICAL CENTER

CORPORATE END-USER MAJOR TECH UPDATE 11/20/14 11/20/2014 8 TECHNICAL EPSON

MINDFULNESS: STRESS REDUCTION TECHNIQUES 08/14/2014 08/14/2014 4 TECHNICAL DR. ARTURO P. PINGOY MEDICAL CENTER

TECH SESSION 01/20/2013 01/20/2013 12 TECHNICAL 1ST ACT CONVENTION

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

COMPUTER LITERATE N/A N/A

COMPUTER TROUBLESHOOTING N/A N/A

ADOBE PHOTOSHOPS N/A N/A

ADOBE ILLUSTRATOR N/A N/A

BASIC PROGRAMMING (JAVA) 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
YES ✘ NO
regulation 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 If YES, give details:
phased 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
YES ✘ NO
(except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
the last 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
a.
items:
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
OMAR B. ALAM ISULAN SULTAN KUDARAT 9163277836 3.5 cm. X 4.5 cm
(passport size)

SURAINA A. KALID ISULAN SULTAN KUDARAT 9164483898 With full and handwritten
name tag and signature over
printed name

Computer generated
or photocopied picture
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and 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 PHOTO
filing of 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: DRIVER LICENSE

ID/License/Passport No.: L05-12-001670

Signature (Sign inside the box)

Date/Place of Issuance: 11/06/2022

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