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 CORTEZ
NAME EXTENSION (JR., SR)
FIRST NAME JESSMAR

MIDDLE NAME ETOC

3. DATE OF BIRTH
(mm/dd/yyyy) 4/7/1976 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH TAGO, SURIGAO 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
Widowed Separated House/Block/Lot No. Street
Other/s: PUROK SANTAN GAMUT
Subdivision/Village Barangay
TAGO SURIGAO DEL SUR
7. HEIGHT (m) 1.56
City/Municipality Province
8. WEIGHT (kg) 79 Kg. ZIP CODE

18. PERMANENT ADDRESS

9. BLOOD TYPE O+
House/Block/Lot No. Street
PUROK PAG-ASA SUMO-SUMO
10. GSIS ID NO. 7604070167
Subdivision/Village Barangay
TAGO SURIGAO DEL SUR
11. PAG-IBIG ID NO. 183000051575
City/Municipality Province

12. PHILHEALTH NO. 180000508312 ZIP CODE 8302

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

14. TIN NO. 932-749-323 20. MOBILE NO. 09079734403

15. AGENCY EMPLOYEE NO. L7200934 21. E-MAIL ADDRESS (if any) [email protected] / [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) 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 CORTEZ

NAME EXTENSION (JR., SR)
FIRST NAME JESUS

MIDDLE NAME BRUZON

25. MOTHER'S MAIDEN NAME

SURNAME ETOC

FIRST NAME NORMA

MIDDLE NAME MONTERO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY GAMUT ELEMENTARY SCHOOL ELEMENTARY 1983 1989 N/A 1989 4TH HONORS

SECONDARY /
VOCATIONAL A. O. FLOIRENDO NATIONAL HIGH SCHOOL HIGH SCHOOL 1990 1994 N/A 1994 6TH HONORS

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

TRADE
COURSE BACHELOR IN SECONDARY EDUCATION Major in
COLLEGE SURIGAO DEL SUR POLYTECHNIC STATE COLLEGE
Math
1996 2000 N/A 2000 None

GRADUATE STUDIES SURIGAO DEL SUR STATE UNIVERSITY Master of Science in Teaching-Math 2001 2004 30 Units N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 1-13-21 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 (LET) 76.60% 8/27/2000 DAVAO CITY 0678152

CAREER SERVICE PROFESSIONAL EXAMINATION 80.27% 3/26/2000 TANDAG CITY

CAREER SERVICE SUB-PROFESSIONAL

86.48% 11/8/1998 CANTILAN, SURIGAO DEL SUR
EXAMINATION

(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)

1/1/2021 PRESENT TEACHER II GAMUT NHS - TAGO 26,336.00 PERMANENT Y

1/1/2020 12/31/2020 TEACHER II GAMUT NHS - TAGO 24,779.00 PERMANENT Y

1/1/2019 12/31/2019 TEACHER II GAMUT NHS - TAGO 23,222.00 PERMANENT Y

6/15/2018 12/31/2018 TEACHER II GAMUT NHS - TAGO 22,410.00 Step 2 PERMANENT Y

1/1/2018 6/14/2018 TEACHER II GAMUT NHS - TAGO 22,149.00 PERMANENT Y

1/1/2017 12/31/2017 TEACHER II GAMUT NHS - TAGO 21,387.00 PERMANENT Y

1/1/2016 12/31/2016 TEACHER II GAMUT NHS - TAGO 20,651.00 PERMANENT Y

6/15/2015 12/31/2015 TEACHER II GAMUT NHS - TAGO 19,940.00 SG-12/Step 1 PERMANENT Y

1/1/2015 6/14/2015 TEACHER I GAMUT NHS - TAGO 19,111.00 Step 4 PERMANENT Y

2/1/2014 12/31/2014 TEACHER I GAMUT NHS - TAGO 18,922.00 PERMANENT Y

7/1/2013 1/31/2014 TEACHER I GAMUT NHS - TAGO 18,549.00 PERMANENT Y

6/1/2012 6/30/2013 TEACHER I MADRID NHS - MADRID 18,922.00 PERMANENT Y

2/1/2012 5/31/2012 TEACHER I MADRID NHS - MADRID 17,540.00 Step 3 PERMANENT Y

6/1/2011 1/31/2012 TEACHER I MADRID NHS - MADRID 17,318.00 PERMANENT Y

6/24/2010 5/31/2011 TEACHER I MADRID NHS - MADRID 15,900.00 PERMANENT Y

7/1/2009 6/23/2010 TEACHER I MADRID NHS - MADRID 14,483.00 Step 2 PERMANENT Y

2/1/2009 6/30/2009 TEACHER I MADRID NHS - MADRID 12,328.00 PERMANENT Y

7/1/2008 1/31/2009 TEACHER I MADRID NHS - MADRID 12,026.00 PERMANENT Y

7/1/2007 1/31/2008 TEACHER I MADRID NHS - MADRID 10,933.00 PERMANENT Y

2/1/2006 6/30/2007 TEACHER I MADRID NHS - MADRID 9,939.00 Step 1 PERMANENT Y

(Continue on separate sheet if necessary)

SIGNATURE DATE 1-13-21 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

NONE

(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
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

TAGO 3 2-DAY SEMINAR WORKSHOP ON ACTION RESEARCH 2/12/2019 3/12/2019 16 TECHNICAL DEPED-TAGO 3 District

TAGO 3 DISTRICT DCP ORIENTATION CUM ICT CAPACITY BUILDING FOR TEACHERS 11/14/2019 11/14/2019 8 TECHNICAL DEPED-TAGO 3 District

TAGO 3 DISTRICT WORKSHOP ON PPST RESOURCE PACKAGE

5/7/2019 07/19/2019 24 TECHNICAL DEPED-TAGO 3 District

PAKIKIPAGKWENTUHAN: THE GUIDANCE ADVOCATES' ROLE IN SCHOOL

11/12/2018 11/13/2018 16 TECHNICAL DEPED-TAGO 2 District

4-day DISTRICT ROLL-OUT OF SPECIAL EDUCATION (SPED) ON INCLUSIVE EDUCATION 9/13/2018 9/14/2018
(IE) 32 TECHNICAL DEPED-TAGO Districts
10/22/2018 10/23/2018
3-DAY 22nd CRAM REGIONAL REFRESHER COURSE ON SPORTS OFFICIATING
8/29/2018 8/31/2018 24 TECHNICAL DEPED CARAGA

3-DAY TAGO 1 AND TAGO 2 DISTRICTS TRAINING ON SPECIFIC LEARNING DISABILITIES

THROUGH INCLUSIVE EDUCATION 1/26/2017 1/28/2017 24 TECHNICAL DEPED-TAGO Districts

3-DAY 21st CRAM REGIONAL REFRESHER COURSE ON SPORTS OFFICIATING 2017

1/11/2017 1/13/2017 24 TECHNICAL DEPED CARAGA

(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
(Write in full)
in full)

SINGING BOY SCOUTS OF THE PHILIPPINES (BSP)

DANCING
DEPED CARAGA ASSOCIATION OF
OFFICIATING OFFICIALS

(Continue on separate sheet if necessary)

SIGNATURE DATE 1-13-21 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 ✘ 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 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? ________________________________
________________________________
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 CELLPHONE #

ID picture taken within
the last 6 months
NANITA U. VILLONES GAMUT, TAGO, SDS 09204010957 3.5 cm. X 4.5 cm
(passport size)

DIVINA C. MALABANAN GAMUT, TAGO, SDS 09090023212 With full and handwritten
name tag and signature over
printed name
LOURDES A. CULIAO GAMUT, TAGO, SDS 09465549064
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
is not acceptable
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 PHOTO
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.: 18-1930896 Signature (Sign inside the box)

Date/Place of Issuance: May 31, 2019/Butuan 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