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 KASAN
NAME EXTENSION (JR., SR)
FIRST NAME MANAR FARIZA

MIDDLE NAME TANTO

3. DATE OF BIRTH
(mm/dd/yyyy) 7/25/1998 16. CITIZENSHIP FILIPINO

4. PLACE OF BIRTH SULTAN KUDARAT MAGUINDANAO If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX FEMALE N/A
17. RESIDENTIAL ADDRESS 724 ANO STREET
6 CIVIL STATUS SINGLE
House/Block/Lot No. Street
POBLACION
Subdivision/Village Barangay
BALIUAG BULACAN
7. HEIGHT (m) 1.60
City/Municipality Province
8. WEIGHT (kg) 58 ZIP CODE 3006

18. PERMANENT ADDRESS 724 ANO STREET

9. BLOOD TYPE A
House/Block/Lot No. Street
POBLACION
10. GSIS ID NO. N/A
Subdivision/Village Barangay
BALIUAG BULACAN
11. PAG-IBIG ID NO. N/A
City/Municipality Province

12. PHILHEALTH NO. 17-050377347 ZIP CODE 3006

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

14. TIN NO. N/A 20. MOBILE NO. 09262610274

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) N/A
FIRST NAME N/A N/A
N/A
MIDDLE NAME N/A N/A
N/A
OCCUPATION N/A 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 KASAN N/A
NAME EXTENSION (JR., SR) N/A
FIRST NAME PARID N/A
N/A
MIDDLE NAME REALSE N/A
N/A
25. MOTHER'S MAIDEN NAME TANTO N/A
N/A
SURNAME KASAN N/A
N/A
FIRST NAME ZUBAIDA N/A

MIDDLE NAME MARTIN (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 GRADUATED
(Write in full) EARNED HONORS
full) (if not graduated) RECEIVED
From To
 SPECIAL
ELEMENTARY MAGUINDANAON ELEMENTARY SCHOOL 2004 2010 N/A 2010
AWARD
COTABATO CITY NATIONAL HIGH SCHOOL- MAIN SPECIAL
SECONDARY
VOCATIONAL / CAMPUS
2010 2014 N/A 2014
AWARD

TESDA VISUAL GRAPHIC DESIGN NCIII 2021 2021 N/A 2021 N/A
TRADE
COURSE
COLLEGE BULACAN STATE UNIVERSITY- BUSTOS CAMPUS PHYSICAL SCIENCE 2016 2020 N/A 2020 DEAN'S LIST

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

(Continue on separate sheet if necessary)

SIGNATURE DATE MARCH 03 2021 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

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

(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)
DR. PABLITO V. MENDOZA SR. HIGH
11/1/2018 11/18/2019 PRACTICE TEACHER N/A N/A N/A N/A
SCHOOL
CENTRO DEPARTMENT STORE COTABATO
1/14/2016 7/15/2016 CASHIER 7000.00 274 N/A N/A
CITY
7/28/2015 12/10/2015 SERVICE CREW JOLLIBEE COTABATO PLAZA 7000.00 272 N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE MARCH 03 2021 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

(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) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To

BASIC PHOTOSHOP SKILLS TRAINING 2/13/2014 2/13/2014 8.0 AMA COLLEGE DOLORES P. BAYONA

"DEVELOPING TEACHING SKILSS TOWARDS PERSONAL AND PROFESSIONAL

3/16/2016 3/16/2016 6.0 BSU BUSTOS
DEVELOPMENT" COED AREA CHAIR
"BUILDING BRIDES: AN ASSEMBLY OF SCIENCE MAJOR STUDENTS TOWARDS
5/10/2017 5/10/2017 8.0 BSU BUSTOS
TRANSFORMING NATION CAMPUS DEAN

"SCIENCE EDUCATION: BEST WEAPON TOWARDS PROGRESS" 11/17/2017 11/17/2017 8.0 BSU BUSTOS
SCIRE CLUB PRESIDENT
"THE CODE OF ETHICS FOR PROFESSIONAL TEACHERS & MAGNA CARTA FOR PUBLIC
5/18/2018 5/18/2018 8.0 BSU BUSTOS
TEACHERS" COED AREA CHAIR

"EQUIPING FUTURE EDUCATORS TO BECOME 21ST CENTURY FILIPINO TEACHERS" 10/17/2018 10/17/2018 8.0 BSU BUSTOS
CAMPUS DEAN

UP ASTRONOMICAL SOCIETY'S LAKBAY LANGIT 11/9/2018 11/9/2018 15.0 BSU BUSTOS

UP LAKBAY LANGIT TEAM

TEAM BUILDING AND SEMINAR "GEARING TODAY THE LEADERS OF TOMORROW" 1/16/2019 1/16/2019 8.0 BSU BUSTOS
BSU STUDENT GOVERNER

BASIC COMPUTER 7/18/2020 7/25/2020 20.0 COP PRESIDENT/OWNER OF APEX

VISUAL GRAPHIC DESIGN NC III 11/16/2020 2/6/2021 501.0 TESDA TESDA

(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)

COMMUNICATION SKILLS N/A N/A

 CASH HANDLING

COMPUTER SKILLS

MS OFFICES LITERATE

GRAPHIC DESIGN SKILLS

MATHEMATICAL SKILLS

MAKE UP ARTIST
(Continue on separate sheet if necessary)

SIGNATURE DATE MARCH 03 2021 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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
NO If YES, give details:
________________________________
________________________________
35. a. Have you ever been found guilty of any administrative offense? NO
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court?
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? 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 If YES, give details:
out (abolition) in the public or private sector?NO ________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)?NO
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last
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?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? NO
If YES, please specify:
b. Are you a person with disability? NO
If YES, please specify ID No:
c. Are you a solo parent? 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
ANO STREET POBLACION BALIUAG the last 6 months
BAIBON T. JUMAT BULACAN
901375406 3.5 cm. X 4.5 cm
(passport size)

PARID KASAN SULTAN KUDARAT MAGUINDANAO 9268339828 With full and handwritten
name tag and signature
over
printed name

Computer generated
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.

42.
or photocopied picture
is not acceptable

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of Issuance
Government Issued ID: N/A

ID/License/Passport No.: N/A

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

Date/Place of Issuance: N/A

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