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 LIBUNA
NAME EXTENSION (JR., SR) N/A
FIRST NAME MARY ROSE

MIDDLE NAME GAGULA

3. DATE OF BIRTH
(mm/dd/yyyy) 16. CITIZENSHIP
4/3/1997 ✘ Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH SAN MIGUEL ILAYA, TAPAZ, CAPIZ If holder of dual citizenship, Pls. indicate country: naturalization
please indicate the details.
5. SEX
Male ✘ Female
6 CIVIL STATUS
17. RESIDENTIAL ADDRESS N/A N/A
✘ Single Married House/Block/Lot No. Street
Widowed Separate N/A SAN MIGUEL ILAYA
Other/s: d Subdivision/Village Barangay

7. HEIGHT (m) 1.549 M TAPAZ CAPIZ

City/Municipality Province
8. WEIGHT (kg) 45 KG 5814

9. BLOOD TYPE O 18. PERMANENT ADDRESS N/A N/A

House/Block/Lot No. Street

10. GSIS ID NO. N/A N/A SAN MIGUEL ILAYA

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121212058925 TAPAZ CAPIZ

City/Municipality Province

12. PHILHEALTH NO. 11-250718245-6 5814

13. SSS NO. 07-3725331-1 19. TELEPHONE NO. N/A

14. TIN NO. 377-612-597-000 20. MOBILE NO. 09556108598

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)
FIRST NAME N/A N/A LIMOGMOG, RHOLIE MAR LIBUNA 07/16/2021

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME LIBUNA

NAME EXTENSION (JR., SR)
FIRST NAME SIMPLICIO SR
MIDDLE NAME FARILLON

25. MOTHER'S MAIDEN NAME

SURNAME GAGULA

FIRST NAME ROSALIE

MIDDLE NAME VILLAREAL (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY KATIPUNAN ELEMENTARY SCHOOL PRIMARY EDUCATION 2003 2009 GRADUATED 2009 3RD HONORABLE

SECONDARY
REV. TOMAS CONEJAR NATIONAL HIGH HIGH SCHOOL 2009 2013 GRADUATED 2013 WITH
VOCATIONAL / SCHOOL HONORS

DUMALAG VOCATIONAL AND TECHNICAL FOOD AND BEVERAGE SERVICES 2018 2018 GRADUATED 2018 N/A
SCHOOL
TRADE
COURSE WEST VISAYAS STATE UNIVERSITY -
COLLEGE
LAMBUNAO CAMPUS BACHELOR IN ELEMENTARY EDUCATION 2013 2017 GRADUATED 2017 N/A

GRADUATE STUDIES GUIMARAS STATE UNVERSITY MASTER IN EDUCATION MAJOR IN 2021 2023 45 UNITS N/A N/A
GENERAL SCIENCE
(Continue on separate sheet if necessary)

SIGNATURE DATE AUGUST 16, 2024

CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY
27. LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER RATING DATE OF
SPECIAL LAWS/ CES/ CSEE (If Applicable) EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT NUMBER Date of
Validity
ILOILO CITY NATIONAL HIGH SCHOOL, MOLO
LICENSURE EXAMINATION FOR TEACHER 75.20% 03/25/2018 ILOILO CITY 1641220 4/3/2027

(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.
28. INCLUSIVE DATES SALARY/ JOB/ GOV'T SERVICE
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY PAY GRADE (if
MONTHLY applicable)& STATUS OF
(Write in full/Do not (Write in SALARY STEP (Format APPOINTMENT
abbreviate) full/Do not abbreviate) "00-0")/
From To INCREMENT (Y/ N)

KINDERGARTEN TEACHER BIBLE BAPTIST LEARNING CENTER ₱ 4, 000 N/A CONTRACTUAL N/A
08/22/2022 07/07/2023 CAGAMUTAN SUR LEGANES INC.

PRE SCHOOL TEACHER TAPAZ CHRISTIAN SCHOOL ₱ 4, 000 N/A CONTRACTUAL N/A
08/23/2021 07/29/2022
PRE SCHOOL TEACHER TAPAZ CHRISTIAN SCHOOL ₱ 4, 000 N/A CONTRACTUAL N/A
08/24/2020 06/28/2021
PRE SCHOOL TEACHER TAPAZ CHRISTIAN SCHOOL ₱ 5, 000 N/A CONTRACTUAL N/A
06/03/2019 03/31/2020
PRE SCHOOL TEACHER BIBLE BAPTIST LEARNING CENTER ₱ 3, 000 N/A CONTRACTUAL N/A
5/6/2018 05/31/2019 CAGAMUTAN SUR LEGANES INC.

PRE SCHOOL TEACHER BIBLE BAPTIST LEARNING CENTER ₱ 3, 000 N/A CONTRACTUAL N/A
3/6/2017 05/31/2018 CAGAMUTAN SUR LEGANES INC.

(Continue on separate sheet if necessary)

SIGNATURE DATE AUGUST 16, 2024

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

FOOD AND BEVERAGES SERVICES NCII 11/15/2018 12/13/2028 356 TECHNICAL DUMALAG VOCATIONAL AND TECHNICAL SCHOOL

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. NON-ACADEMIC DISTINCTIONS / RECOGNITION (Write in full) 33. (Write in
full)

COMPUTER LITERATE N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE AUGUST 16, 2014

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
by any court or tribunal? YES ✘ NO
If YES, give details:
________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation,
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased YES ✘ NO
out (abolition) in the public or private sector? If YES, give details:
________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? YES ✘ NO
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last YES
election to promote/actively campaign for a national or local candidate? ✘ NO
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
NO
If YES, please specify: PANAY BUKIDNON
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
MERLY C. BECODO SAN MIGUEL ILAYA, TAPAZ, CAPIZ N/A 4.5 cm. X 3.5 cm
(passport size)
RO BLANCAFLOR SAN MIGUEL ILAYA, TAPAZ, CAPIZ N/A
Computer generated
or photocopied picture
MADELIN G. LIMOGMOG SAN MIGUEL ILAYA, TAPAZ, CAPIZ N/A 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
administrative/criminal case/s against me. PHOTO

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.: 1641220 Signature (Sign inside the box)

AUGUST 16, 2024
Date/Place of Issuance: 03/24/2018 - ILOILO 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