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 Reyes
NAME EXTENSION (JR., SR)
FIRST NAME Leovi May

MIDDLE NAME Nanat

3. DATE OF BIRTH
(mm/dd/yyyy) 5/11/1998 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH Bangan-Oda, Agno, Pangasinan If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS Sitio San Bruno
Widowed Separated House/Block/Lot No. Street
Bangan-Oda
Other/s:
Subdivision/Village Barangay
Agno Pangasinan
7. HEIGHT (m)
City/Municipality Province
8. WEIGHT (kg) 84 ZIP CODE 2408

18. PERMANENT ADDRESS Sitio San Bruno

9. BLOOD TYPE B
House/Block/Lot No. Street
Bangan-Oda
10. GSIS ID NO. N/A
Subdivision/Village Barangay
Agno Pangasinan
11. PAG-IBIG ID NO. 121257340810
City/Municipality Province

12. PHILHEALTH NO. 05-253146352-8 ZIP CODE 2408

13. SSS NO. 34-8706908-5 19. TELEPHONE NO.

14. TIN NO. 771-248-745 20. MOBILE NO. 09978434332

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME Reyes 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) Athyleighia Hesed Cryle Nanat Reyes
FIRST NAME Cristian 7/20/2020
Izecristleghr Adam Cryle Nanat Reyes
MIDDLE NAME Camposano 7/5/2021

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME Nanat

NAME EXTENSION (JR., SR)
FIRST NAME Virgilio

MIDDLE NAME Tesoro

25. MOTHER'S MAIDEN NAME

SURNAME Rosete

FIRST NAME Nora

MIDDLE NAME Nanat (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
HONORS
(Write in full)
full) (if not graduated) RECEIVED
From To

ELEMENTARY Don Aurelio Evangelista Memorial Elementary School Elementary 6/1/2004 3/30/2010 2010 Salutatorian

SECONDARY /
VOCATIONAL Bangan-Oda National High School Secondary 6/1/2010 3/27/2014 2014 Salutatorian

TRADE
Bachelor of Elementary Education Major in Early
COURSE
COLLEGE Harris Memorial College
Childhood Education
6/14/2014 3/30/2020 2020 Dean's Lister

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE February 13, 2024

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

Licensed Professional Teacher 88.4 10/3/2022 Bayambang, Pangasinan 1961401 5/11/2026

(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)
Preschool-Elementary Department
8/22/2023 Present Harris Memorial College P16,100 N/A Contructual No
Coordinator and Elementary Teacher
9/1/2022 7/15/2023 Elementary Teacher Harris Memorial College P14,00 N/A Contructual No
Junior League and Sunday School Teacher
9/1/2020 12/31/2020 Agno United Methodis Church P2,000 N/A Continuous No
and Church Worker
Junior League and Sunday School Teacher
1/1/2021 12/31/2021 Agno United Methodis Church P2,200 N/A Continuous No
and Church Worker
Junior League and Sunday School Teacher
1/1/2022 1/11/2022 Agno United Methodis Church P2,200 N/A Continuous No
and Church Worker

(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

(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

Teaching English as a Foreign Language Course 5/15/2021 5/30/2021 120 hours N/A TEFL Professional Institute-Teacher Record

Inservice Training (INSET) 8/22/2022 8/24/2022 24 hours N/A

Harris Memorial College, INC.

Inservice Training (INSET) 8/16/2023 8/18/2023 24 hours N/A

Harris Memorial College, INC.

Sunday School Teachers' Workshop "Building an Effective Kids Sunday School" 2/3/2023 2/3/2023 3 hours N/A
River of Life Methdist Church
Classroom Management Mastery: Behavior and Psychology Essentials 2/16/2024 2/16/2024 3 hours N/A
Career Advancement andLifelong Learning Institute

(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)

Singing Outstanding Piano Recitalist

Playing Piano

Playing other Musical Instruments

Computer Literate

Digital Designing Skills

(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 ✘

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? ________________________________
end of contract
________________________________
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
4.5 cm. X 3.5 cm
(passport size)

Computer generated
or photocopied picture
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.: 1961401

Signature (Sign inside the box)

Date/Place of Issuance: 02/20/2023

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