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 FUERZAS
NAME EXTENSION (JR., SR)
FIRST NAME KAREN MAE

MIDDLE NAME ALISACA

3. DATE OF BIRTH
(mm/dd/yyyy) 03/27/1998 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH APOKON, TAGUM CITY 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 4, UNIT 1
Widowed House/Block/Lot No. Street
Separated APOKON
Other/s:
Subdivision/Village Barangay
TAGUM DAVAO DEL NORTE
7. HEIGHT (m) 1.60
City/Municipality Province
8. WEIGHT (kg) 52 ZIP CODE

18. PERMANENT ADDRESS PUROK 4, UNIT 1

9. BLOOD TYPE A
House/Block/Lot No. Street
APOKON
10. GSIS ID NO.
Subdivision/Village Barangay
TAGUM DAVAO DEL NORTE
11. PAG-IBIG ID NO. 919134024786
City/Municipality Province

12. PHILHEALTH NO. 16-250314948-6 ZIP CODE 8100

13. SSS NO. 0111-9718596-3 19. TELEPHONE NO.

14. TIN NO. 392-115-439-0000 20. MOBILE NO. 09501295220

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 N/A N/A

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME FUERZAS

JR.
FIRST NAME VICTORINO

MIDDLE NAME JALA

25. MOTHER'S MAIDEN NAME

SURNAME ALISACA

FIRST NAME SALVACION

MIDDLE NAME DEGAMO (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 APOKON ELEMENTARY SCHOOL N/A 2004 2009 2009

SECONDARY TAGUM NATIONAL TRADE SCHOOL FOODS TRADE 2010 2013 2013
VOCATIONAL /
REGIONAL TRAINING CENTER-DAVAO/KOREA
VOCATIONAL
COOKERY 2019 2019 2019
TRADE
COURSE
BACHELOR OF SECONDARY EDUCATION MAJOR IN
COLLEGE UNIVERSITY OF MINDANAO TAGUM COLLEGE ENGLISH 2014 2018 2018

GRADUATE STUDIES UNIVERSITY OF MINDANAO TAGUM COLLEGE MASTER OF ARTS IN EDUCATION MAJOR IN ENGLISH 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
UNIVERSITY OF MINDANAO, MATINA, DAVAO
LICENSURE EXAMINATION FOR TEACHERS 82 3/24/2019 1773380 06/14/2019
CITY
DAVAO CITY NATIONAL HIGH SCHOOL, DAVAO
CIVIL SERVICE EXAMINATION 80. 26 3/17/2019 406116 05/202019
CITY

(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)
TAGUM CITY COLLEGE OF SCIENCE AND
8/1/2022 PRESENT JHS & SHS TEACHER 9500 CONTRACT N
TECHNOLOGY FOUNDATION, INC.
9/1/2021 6/30/2022 ALS TEACHER TAGUM CITY NATIONAL HIGH SCHOOL 7500 CONTRACT Y

1/1/2021 6/30/2021 LEARNING SUPPORT AIDE APOKON ELEMENTARY SCHOOL 9,000 CONTRACT Y
STO. NIÑO COLLEGE OF SCIENCE AND
6/13/2019 3/30/2020 JHS TEACHER 9000 CONTRACT N
TECHNOLOGY, INCORPORATED

(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
PACKAGING OF RELIEF GOODS FOR VICTIMS OF TYPHOON ODETTE FROM ST.
01/05/2022 1/5/2022 8 VOLUNTEER
THOMAS MORE SCHOOL OF LAW AND BUSINESS

TAGUM MUSICIANS ASSOCIATION 8/11/2019 1/20/2021 320 SECRETARY

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

LAC (Mentoring for Teachers' Development and Right Conduct) 12/29/2022 12/29/2022 8 TCCSTFI at Mati City

Coaching Davao del Norte Interschoolastic Press Freedom Competition 11/12/2022 11/12/2022 8 Davao del Norte Provincial Capitol

Coaching, Mentoring, and Training Relevant in Facilitating Blended Learning 08/13/2022 08/13/2022 8 TCCSTFI Audio Visual Room

Training as a Guidance Advocate for Psychological First Aid 8/4/2022 8/5/2022 16 TCCSTFI Audio Visual Room

Division Training for the Utilization of Mobile Technology for Teacher (MT4T) 02/09/2022 02/11/2022 24 ALS SUPERVISORS

Tagum City Poem Writing Competition - 5th place 01/03/2022 01/03/2022 8 LGU - TAGUM

Research Reactor in the UMTC's Research Forum 12/27/2021 12/27/221 4 UM TAGUM COLLEGE

International Webinar on Alternative Learning Center 8/30/2021 8/30/2021 8 ALS SUPERVISORS

"Bida si Teacher" 2021 National Women's Month Celebration - Champion 3/30/2021 3/30/2021 8 APOKON ELEMENTARY SCHOOL

Technical Working Group of 2021 - Women's Month Celebration 3/30/2021 3/30/2021 4 APOKON ELEMENTARY SCHOOL

Orientation on Administrative Cases, Ethics, & Norms in Public Service 3/26/2021 3/26/2021 4 APOKON ELEMENTARY SCHOOL

Lip Sync Battle Competition (Champion) - Winning Coach 2/22/2020 2/22/2020 24 STO. NIÑO COLLEGE OF SCIENCE AND TECH, INC.

"CLEAN TO WIN" - FIRST PLACE 1/12/2020 1/12/2020 4 STO. NIÑO COLLEGE OF SCIENCE AND TECH, INC.

"CLEAN TO WIN" - THIRD PLACE 11/8/2019 11/8/2019 4 STO. NIÑO COLLEGE OF SCIENCE AND TECH, INC.

5TH WINNING COACH IN DSPC - EDITORIAL WRITING 11/8/2019 11/8/2019 24 DIVISION SCHOOLS PRESS CONFERENCE

Division Training for Campus Journalists and School Paper Advisers 7/23/2020 10/20/2020 160 DIVISION SCHOOLS PRESS CONFERENCE

NC2 - COOKERY 7/12/2019 10/8/2019 220 TESDA

(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)

EXCELLENT IN WRITING SKILLS 5TH WINNING COACH IN EDITORIAL WRITING DIVISION SCHOOLS' PRESS CONFERENCE

WRITING TOP 5 IN TAGUM CITY POEM WRITING COMPETITION TAGUM CITY GENERAL SERVICES OFFICE

LITERATE IN MICROSOFT WORDS EXPERIENCE

BASS GUITARIST FORMER SECRETARY IN TAGUM MUSICIANS ASSOCIATION TAGUM MUSICIANS' ASSOCIATION

COOKING NC-II PASSER REGIONAL TRAINING CENTER-DAVAO/KOREA

(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
KIM JONEL G. GREGORIO GEMINI VILLAGE, TAGUM CITY 09101917148 4.5 cm. X 3.5 cm
(passport size)

MEDOS JALA CAPITOL, TAGUM CITY

Computer generated
or photocopied picture
RAFAEL BRIAN D. AGRAVIADOR 1155 SISON SUBDIVISION, TAGUM CITY 09501317983 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:

ID/License/Passport No.: 1773380

Signature (Sign inside the box)

Date/Place of Issuance: MARCH 27, 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