CS Form No.

212

PERSONAL DATA SHEET

Revised 2017

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 ACCOM PLISHING 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 VALGUNA
NA M E EXTENSION (JR., SR)
FIRST NAME LADY ANGEL

MIDDLE NAME IGNACIO

3. DATE OF BIRTH
12/10/1997 16. CITIZENSHIP
Filipino Dual Citizenship
(mm/dd/y y y y )
by birth by naturalization
4. PLACE OF BIRTH POBLACION JAMINDAN, CAPIZ If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female

Single Married 17. RESIDENTIAL ADDRESS SAN ANTONIO

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
POBLACION
Other/s:
Subdivision/Village Barangay
JAMINDAN CAPIZ
7. HEIGHT (m) 1.49
City/Municipality Province
8. WEIGHT (kg) 49 ZIP CODE 5808

18. PERMANENT ADDRESS SAN ANTONIO

9. BLOOD TYPE o
House/Block/Lot No. Street
POBLACION
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A JAMINDAN CAPIZ

City/Municipality Province
12. PHILHEALTH NO. N/A ZIP CODE 5808

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

14. TIN NO. N/A 20. MOBILE NO. 09104706905

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any ) valgunaladyangel@yahoo.com
II. FAMILY BACKGROUND
DATE OF BIRTH
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
(mm/dd/y y y y )
NA M E EXTENSION (JR., SR) N/ A
FIRST NAME N/A N/A

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME VALGUNA

SR
FIRST NAME RONIE

MIDDLE NAME VILLEZA

25. MOTHER'S MAIDEN NAME YVONNE LUSANTA IGNACIO

SURNAME VALGUNA

FIRST NAME YVONNE

MIDDLE NAME IGNACIO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST SCHOLA RS
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE P ERIOD OF A TTENDA NCE LEVEL/
YEA R
HIP /
LEVEL UNITS A CA DEM IC
(Write in full) (Write in full) EA RNED
GRA DUA TED
HONORS
From To (if no t RECEIVED
JAMINDAN ELEMENTARY
ELEMENTARY E LE M E N T A R Y 06/06/2004 03/ 31/ 2010 GRADUAT E D
2010 N/A
SCHOOL
JAMINDAN NATIONGAL HIGH WITH
SECONDARY H IG H S C H O O L 06/07/2010 03/31/2014 GRADUAT E D
2014
SCHOOL HONORS
VOCATIONAL /
N/A N/A N/A N/A N/A N/A N/A
TRADE COURSE
CAPIZ STATE UNIVERSITY-MAIN BACHELOR OF SECONDARY GSIS/
COLLEGE 06/10/2014 04/03/2018 GRADUAT E D
2018
CAMPUS EDUCATION-MAJOR IN MAPEH C U M LA U D E

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE SEPTEMBER 10, 2019

CS FORM 212 (Revised 2017), P age 1o f 4

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) DATE OF LICENSE (if applicable)
RATING
UNDER SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT Date of
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT Validity

LICENSURE EXAMINATION FOR TEACHERS 0.8 09/30/2018 ILOILO NATIONAL HIGH SCHOOL 1740625 12/10/2022

(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.
SALARY/
28. INCLUSIVE DATES DEPARTMENT / AGENCY / OFFICE / JOB/ PAY
POSITION TITLE M ONTH GRADE (if STA TUS OF GOV'T
(mm/dd/y y y y ) COMPANY LY applicable)& A P P OINTM EN SERVICE
(Write in full/Do not abbrev iate) SA LA RY STEP T (Y/ N)
From (Write in full/Do not abbrev iate)
To (Format " 00-
0" )/

05/01/2017 05/31/2017 ASSISTANT CLERK MCR OF LGU-JAMINDAN 5000.00 DONE Y

(Continue on separate sheet if necessary)

SIGNATURE DATE SEPTEMBER 10, 2019

CS FORM 212 (Revised 2017), P age 2 o f 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. NUM BER OF
(Write in full) (mm/dd/y y y y ) HOURS
POSITION / NATURE OF WORK
From To
PARISH PASTORAL COUNCIL/POBLACION
08/15/19 PRESENT 520.0 MUSIC MINISTRY PRESIDENT
JAMINDAN, CAPIZ

(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)
TITLE OF LEARNING AND DEVELOPMENT INCLUSIVE DATES OF Type o f LD
30. NUM BER OF ( M anagerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE HOURS Superviso ry/ (Write in full)
(Write in full) From To Technical/etc)

MASSAGE THERAPY NC II 07/14/2018 09/25/2018 720.0 TESDA

PHILIPPINE FOLK DANCE ASSOCIATION 09/21/2017 09/22/2018 8.0 CAPIZ PHILIPPINE FOLKDANCE
CHORAL CONDUCTING 08/15/2016 08/16/2016 4.0 CAPIZ PROVINCIAL CULTURAL OFFICE
FIRST AID TRAINING & WORKSHOP 08/19/2016 08/25/2016 4.0 CAPIZ EMERGENCY RESPONSE TEAM

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMBERSHIP IN
31. SPECIAL SKILLS and HOBBIES 33.
(Write in full) ASSOCIATION/ORGANIZATION
2ND PLACE-LIVE BAND COMPETITION- PASUC
WRITING CAPSU CIRCLE OF PEHM & MAPEH
REGIONAL-AKLAN
3RD PLACE-LIVE BAND COMPETITION- PASUC PERFORMANCE GOVERNANCE
SINGING
REGIONAL-ANTIQUE SYSTEM(JAMINDAN CHAPTER)
DRIVING

DANCING

(Continue on separate sheet if necessary)

SIGNATURE DATE SEPTEMBER 10. 2019

CS FORM 212 (Revised 2017), P age 3 o f 4

34. Are you related by consanguinity or affinity to the appointing or recommending authority, or
chief of bureau or office or to the person who has immediate supervision over you in the
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 YES NO
regulation 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 If YES, give details:
phased 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 YES NO
(except Barangay election)? If YES, give details:

b. Have you resigned from the government service during the three (3)-month period YES NO
before the last 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
a following
Are you aitems:
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
MRS. ELISA V. ROBLES POBLACION JAMINDAN, CAPIZ 9381792983 3.5 cm. X 4.5 cm
(passport size)

DR. SUSAN A. DIOSALAN MILIBILI ROXAS, CITY 9189626332 With f ull and handwritten
name tag and signature ov er
printed name
MISS QUINN NEX V. LOPEZ POBLACION JAMINDAN, CAPIZ 9509371704
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct or photocopied picture
is not acceptable
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 PHOTO
filing of administrative/criminal case/s against me.

Gov ernment Issued ID (i.e.P asspo rt, GSIS, SSS, P RC, Driver's
License, etc.) PLEASE INDICATE ID Number
Gov ernment Issued ID: PRC LICENSE

ID/License/Passport No.: 1740625

Signature (Sign inside the box )
SEPTEMBER 10, 2019
Date/Place of Issuance: 01/24/2019-ILOILO CITY
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant ex hibiting his/her v alidly issued gov ernment ID as indicated abov e.

MA. SHARON S. BARRIENTOS

Person Administering Oath
HUMAN RESOURCE MANAGEMENT OFFICER II/
ADMINISTRATIVE OFFICER IV
POSITION

CS FORM 212 (Revised 2017), P age 4 o f 4