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 DULNUAN
NAME EXTENSION (JR., SR)
FIRST NAME AMELYN

MIDDLE NAME GADDOL

3. DATE OF BIRTH
(mm/dd/yyyy) 4/21/1988 16. CITIZENSHIP
✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH TALIKTIK, CORDON ISABELA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX
Male ✘ Female
17. RESIDENTIAL ADDRESS PUROK 06
6 CIVIL STATUS Single ✘ Married House/Block/Lot No. Street
Widowed Separate TALIKTIK
Other/s: d Subdivision/Village Barangay
CORDON ISABELA
7. HEIGHT (m) 5'
City/Municipality Province
8. WEIGHT (kg) 54 ZIP CODE 3312
18. PERMANENT ADDRESS PUROK 06
9. BLOOD TYPE B+
House/Block/Lot No. Street
TALIKTIK
10. GSIS ID NO. N/A
Subdivision/Village Barangay
CORDON ISABELA
11. PAG-IBIG ID NO. N/A
City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 3312

13. SSS NO. N/A 19. TELEPHONE NO. N/A

14. TIN NO. 451-539-912-000 20. MOBILE NO. 09537303324

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME DULNUAN 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME ACE JUSTINE CLYDE G. DULNUAN 4/23/2016
JEWARD
MIDDLE NAME PASTOR ANNE JHELYN NICOLE G. DULNUAN 3/12/2019

OCCUPATION FARMING ARCH ANGEL JAKE G. DULNUAN 8/24/2023

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME GADDOL

NAME EXTENSION (JR., SR)
FIRST NAME
BASILIO
MIDDLE NAME PAHALON

25. MOTHER'S MAIDEN NAME LADAONA

SURNAME GADDOL

FIRST NAME REBECCA

MIDDLE NAME POLLAG (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

2ND HON.
ELEMENTARY CABUAAN ELEMENTARY SCHOOL ELEMENTARY 1995 2001 GRADUATED 2001 MENTION

SECONDARY HALIAP NATIONAL SCHOOL HIGH SCHOOL 2002 2007 GRADUATED 2007
VOCATIONAL /
3RD HON.
MENTION
N/A N/A N/A N/A N/A N/A
TRADE
COURSE
NUEVA VIZCAYA STATE UNIVERSITY BACHELOR IN ELEMENTARY 2008 2012 GRADUATED 2012 DIPLOMA
EDUCATION
COLLEGE

GRADUATE STUDIES NORTHEASTERN COLLEGE MASTERS IN EDUCATION 2022 2023 36 UNITS N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE February 12, 2025

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

LICENSURE EXAMINATION FOR TEACHERS (LET) 77.4 30/09/2012 TUGUEGARAO 1148981 4/21/2027

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

1/3/2023 6/30/2023 TEACHER TALIKTIK INTEGRATED SCHOOL 2000.00 N/A CONTRACTUAL Y

1/8/2022 12/30/2022 TEACHER TALIKTIK INTEGRATED SCHOOL 2000.00 N/A CONTRACTUAL Y

1/7/2023 1/7/2014 DAYCARE WORKER CABUAAN, BAYOMBONG, NUEVA 5000.00 N/A HONORARIU Y
VIZCAYA M

(Continue on separate sheet if necessary)

SIGNATURE DATE FEBRUARY 12, 2025

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 NUMBER OF
(Write in full) HOURS POSITION / NATURE OF WORK
(mm/dd/yyyy)
From To

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 CONDUCTED/ SPONSORED BY (Write in full)

30. TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
NUMBER OF ( Managerial/
INTERVENTIONS/TRAINING PROGRAMS (Write HOURS Supervisory/
in full) (mm/dd/yyyy)
Technical/etc)
From To
LEGISLATIVE REFRESHER COURSE AND
ACCREDITATION FOR SPORTS
4/2/2023 5/2/2023 16 HOURS TECHNICAL CORDON NATIONAL HIGH SCHOOL
COACHES AND TECHNICAL OFFICIALS

MICROSOFT OFFICE APPLICATION 13/04/2017 29/04/2017 15 HOURS TECHNICAL VICS COLLEGE

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

COMPUTER LITERATE N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE FEBRUARY 12, 2025

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
If YES, please specify: IFUGAO
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
MERCY M. BANGLIG WIGAN, CORDON ISABELA 3.5 cm. X 4.5 cm
(passport size)

PIO B. TAYABAN TALIKTIK CORDON ISABELA With full and handwritten

name tag and signature over
printed name
REY B. PAGADDOT TALIKTIK CORDON ISABELA
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied picture
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable
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 ID

ID/License/Passport No.: 2025671 Signature (Sign inside the box)

FEBRUARY 12, 2025
Date/Place of Issuance: 04/17/2023 ROBINSONS STGO. CITY
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.

REY B. PAGADDOT
Person Administering Oath

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