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 GARDOSE
NAME EXTENSION (JR., SR)
FIRST NAME JESSIE JEM

MIDDLE NAME

3. DATE OF BIRTH
5/12/1992 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH AGUSAN DEL SUR 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 19, PHASE 2 LOMBOY A

Widowed House/Block/Lot No. Street

✘ Separate
STO NINO
Other/s: d
Subdivision/Village Barangay
DAVAO CITY DAVAO DEL SUR
7. HEIGHT (m) 5'6''
City/Municipality Province
8. WEIGHT (kg) 92Kg ZIP CODE 8000

18. PERMANENT ADDRESS PUROK 19, PHASE 2 LOMBOY A

9. BLOOD TYPE O+
House/Block/Lot No. Street
10. GSIS ID NO. 2005526092 STO NINO

DAVAO CITY DAVAO DEL SUR

11. PAG-IBIG ID NO. 121054762756
City/Municipality Province

12. PHILHEALTH NO. 16-050470577-0 ZIP CODE 8000

13. SSS NO. 0111-5476156-6 19. TELEPHONE NO.

14. TIN NO. 410-165-925 20. MOBILE NO. 0985 552 9297
15. AGENCY EMPLOYEE NO. 7084040 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME GARDOSE 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME MA. LUZ TREVOUR JYM GARDOSE 5/17/2018

MIDDLE NAME SISBREŃO

OCCUPATION TEACHER - SUBJECT COORDINATOR

EMPLOYER/BUSINESS NAME HOLY CHILD COLLEGE OF DAVAO

BUSINESS ADDRESS E. JACINTO ST., DAVAO CITY

TELEPHONE NO. 0985 552 9298

24. FATHER'S SURNAME GARDOSE

NAME EXTENSION (JR., SR)
FIRST NAME JIMMY

MIDDLE NAME BANER

25. MOTHER'S MAIDEN NAME

SURNAME CAMINGAW

FIRST NAME CRISTITA

MIDDLE NAME RUEDAS (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 ANGEL VILLARICA CENTRAL ELEMENTARY SCHOOL ELEMENTARY 6/7/2004 3/31/2006 GRADUATED 2006

SECONDARY /
VOCATIONAL ASSUMPTION COLLEGE OF DAVAO SECONDARY 6/2/2008 3/30/2010 GRADUATED 2010

BROKENSHIRE COLLEGE HOUSEKEEPING NC II 8/18/2018 11/18/2018 COMPLETED 2018

TRADE
BACHELOR OF ELEMENTARY EDUCATION -
COURSE
COLLEGE ASSUMPTION COLLEGE OF DAVAO
GENERALIST
6/3/2010 4/14/2014 GRADUATED 2014

MASTER OF ARTS IN EDUCATIONAL UNDER

GRADUATE STUDIES UNIVERSITY OF IMMACULATE CONCEPTION
MANAGEMENT
8/5/2023 12/16/2023 9 UNITS
GRADUTE
(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 76.0 8/17/2014 UNIVERSITY OF SOUTHEASTERN PHILIPPINES 1330858 5/12/2027

(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)

11/7/2018 1/9/1900

(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

(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)

(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? ________________________________
RESIGNATION
________________________________
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
HAZEL N. LINAZA TALOMO, DAVAO CITY 0925 517 3361 4.5 cm. X 3.5 cm
(passport size)

ANN A. VELEZ MAA, DAVAO CITY

Computer generated
or photocopied picture
MARILYN L. MARCELO BRGY. STO. NINO, DAVAO CITY 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.: 1330858

Signature (Sign inside the box)

Date/Place of Issuance: 11/2024 / DAVAO 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