CS Form No.

212
Revised 2017
PERSONAL DATA SHEET
WARNING: Any misinterpretation 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 PALUBON
NAME EXTENSION (JR., SR) N/A
FIRST NAME MARCELINA

MIDDLE NAME LABRADOR

3. DATE OF BIRTH
(mm/dd/yyyy) 10/5/1988 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH BAGANIAN, TABINA, ZAMBOANGA DEL SUR If holder of dual citizenship, Pls. indicate country: naturalization
please indicate the details.
5. SEX
Male ✘ Female
17. RESIDENTIAL ADDRESS N/A N/A
6 CIVIL STATUS
Single ✘
House/Block/Lot No. Street
Widowed Married
Separat PUROK DALAMAN DOÑA JOSEFINA
Other/s: ed Subdivision/Village Barangay
TABINA ZAMBOANGA DEL SUR
7. HEIGHT (m)
5.1 City/Municipality Province
8. WEIGHT (kg) 60 kg ZIP CODE 7034

18. PERMANENT ADDRESS N/A N/A

9. BLOOD TYPE 0+
House/Block/Lot No. Street
PUROK DALAMAN DOÑA JOSEFINA
10. GSIS ID NO. 2004597958
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121126989764 TABINA ZAMBOANGA DEL SUR

City/Municipality Province

12. PHILHEALTH NO. 142013244730 ZIP CODE 7034

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

14. TIN NO. 456754631000 20. MOBILE NO. 09487220476

15. AGENCY EMPLOYEE NO. 1500484 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME PALUBON 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME ALDRIN

NAME EXTENSION (JR., SR)
N/A
N/A N/A

MIDDLE NAME TAMULA N/A N/A

OCCUPATION TEACHING N/A N/A

EMPLOYER/BUSINESS NAME N/A N/A N/A

BUSINESS ADDRESS N/A N/A N/A

TELEPHONE NO. N/A N/A N/A

24. FATHER'S SURNAME LABRADOR N/A N/A

FIRST NAME GREGORIO

NAME EXTENSION (JR., SR)
SR.
N/A N/A

MIDDLE NAME LIBRANDO N/A N/A

25. MOTHER'S MAIDEN NAME

N/A N/A

SURNAME ABANIEL N/A N/A

FIRST NAME AURELIA N/A N/A

MIDDLE NAME ARCALA (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 BALONGATING ELEMENTARY SCHOOL PRIMARY EDUCATION 6/18/1996 3/28/2002 N/A 2002 5TH HONORS

3RD
SECONDARY BALONGATING NATIONAL HIGH SCHOOL HIGH SHOOL 6/6/2002 3/30/2006 N/A 2006 HONORABLE
VOCATIONAL / MENTIONED

TRADE
COURSE
COLLEGE JH CERILLES STATE COLLEGE BACHELOR OF ELEMENTARY EDUCATION 6/5/2006 4/11/2009 N/A 2009

MASTER OF ARTS IN EDUCATION

GRADUATE STUDIES SOUTHERN MINDANAO COLLEGES (ADMINISTRATION AND SUPERVISION 7/11/2017 7/10/2019 36 UNITS 2019 N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE January 13,2025 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 79.60 9/28/2009 PAGADIAN CITY 1092943 11/15/2009

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

1/1/2023 PRESENT TEACHER-1 DEPARTMENT OF EDUCATION, TABINA 11 REGULAR Y

PERMANENT
1/1/2022 31//12/2022 TEACHER-1 DEPARTMENT OF EDUCATION, TABINA 26012.00 11 REGULAR Y
PERMANENT
1/1/2021 31//12/2021 TEACHER-1 DEPARTMENT OF EDUCATION, TABINA 24450.00 11 REGULAR Y
PERMANENT
1/1/2020 12/31/2020 TEACHER-1 DEPARTMENT OF EDUCATION, TABINA 22316.00 11 REGULAR Y
PERMANENT
1/1/2019 12/31/2019 TEACHER-1 DEPARTMENT OF EDUCATION, TABINA 22316.00 11 REGULAR Y
PERMANENT
1/1/2018 12/31/2018 TEACHER-1 DEPARTMENT OF EDUCATION, TABINA 19620.00 11 REGULAR Y
PERMANENT
1/1/2017 12/31/2017 TEACHER-1 DEPARTMENT OF EDUCATION, TABINA 19620.00 11 REGULAR Y
PERMANENT
1/1/2016 12/31/2016 TEACHER-1 DEPARTMENT OF EDUCATION, TABINA 19077.00 11 REGULAR Y
PERMANENT
10/28/2015 12/31/2015 TEACHER-1 DEPARTMENT OF EDUCATION, TABINA 19077.00 11 REGULAR Y
PERMANENT
6/9/2014 8/7/2014 TEACHER-1 DEPARTMENT OF EDUCATION, TABINA 19077.00 11 SUBSTITUTE Y

1/16/2014 3/14/2014 TEACHER-1 DEPARTMENT OF EDUCATION, TABINA 19077.00 11 SUBSTITUTE Y

1/31/2013 3/21/2013 TEACHER-1 DEPARTMENT OF EDUCATION, TABINA 19077.00 11 SUBSTITUTE Y

10/21/2012 12/13/2012 TEACHER-1 DEPARTMENT OF EDUCATION, TABINA 19077.00 11 SUBSTITUTE Y

N/A N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE January 13, 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
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

YOUNG CATHOLIC FAITH ORGANIZATION 6/5/2004 4/11/2008 4 YEARS PRESIDENT/CONDUCT BIBLE STUDY IN SCHOOL CAMPUS

ALLIANCE FOR VOLUNTEERS ORGANIZATION 6/10/2005 4/11/2008 3 YEARS PRESIDENT/ENCOURAGING POOR BUT DESERVING STUDENTS TO
MAINTAIN GRADE STANDARDS AS SCHOLAR

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

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

(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
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

Cascading on ICT in the Classroom: Innovative Tools to facilitate 10/10/2022 10/12/2022 24 TECHNICAL DEPARTMENT OF EDUCATION
Students' Learning, Collaborative, and Creativity
Infection Prevention and Control in Schools 6/9/2022 6/9/2022 8 TECHNICAL DEPARTMENT OF EDUCATION

Regional Simulataneous Demonstration of Galaw Pilipinas 08/20/2022 08/20/2022 8 TECHNICAL DEPARTMENT OF EDUCATION

3 Day District Orientation Workshop on the Physical Fitness Test and 05/25/2022 05/27/2022 24 TECHNICAL DEPARTMENT OF EDUCATION
Galaw Pilipinas: The National Calisthenics Exercise Program
District Roll-Out of Gender and Development Guidelines and Gender 11/25/2021 11/25/2021 8 TECHNICAL DEPARTMENT OF EDUCATION
Mainstreaming
District Science Development of Learning Activity Sheets(LAS) and 09/29/2021 09/30/2021 16 TECHNICAL DEPARTMENT OF EDUCATION
Summative Test to ensure quality learning in grades 1 to 6
Implementation of the Learning Delivery Modalities( LDM) 2 Course for the
Insructional Coaches and Teachers under the Basic Education-Learning 09/21/2020 09/25/2020 40 TECHNICAL DEPARTMENT OF EDUCATION
Continuity Plan

2-Day District Wide Roll Out on the Preparation of Annual 1/9/2020 1/10/2020 16 TECHNICAL DEPARTMENT OF EDUCATION
Implementation Plan(AIP) Year 2
N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A

(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)

DANCING N/A PHILIPPINE PUBLIC SCHOOL TEACHERS

ASSOCIATION

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE January 13, 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)? NO
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
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 specify:
If YES, please
✘ NO
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
JOSEPH L. MONTECILLO DOÑA JOSEFINA, TABINA, ZDS 9487220476 3.5 cm. X 4.5 cm
(passport size)
SUSTENIS B. ARAÑA MABUHAY, TABINA, ZDS 9097418189 With full and handwritten
name tag and signature over
printed name
JEREMY S. OLIVER CONCEPCION, TABINA, ZDS 9092397997
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete or photocopied picture
statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. I is not acceptable
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/License/Passport No.: 1092943

Signature (Sign inside the box)
January 13, 2025
Date/Place of Issuance: 09/14/2011 - PAGADIAN 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