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 LAYCANO
NAME EXTENSION (JR., SR)
FIRST NAME RODOLFO

MIDDLE NAME ESMEJARDA JR

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 6/2/1988 ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH MAGDALENA LAGUNA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX
✘ Male Female
17. RESIDENTIAL ADDRESS
6 CIVIL STATUS ✘ Single Married House/Block/Lot No. Street
Widowed BAANAN
Other/s: Separated
Subdivision/Village Barangay
MAGDALENA LAGUNA
7. HEIGHT (m) 180.34
City/Municipality Province
8. WEIGHT (kg) 65 ZIP CODE
18. PERMANENT ADDRESS
9. BLOOD TYPE O
House/Block/Lot No. Street
BAANAN
10. GSIS ID NO. 2004562840
Subdivision/Village Barangay

11. PAG-IBIG ID NO.

MAGDALENA LAGUNA
City/Municipality Province
12. PHILHEALTH NO. ZIP CODE 4007

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 293986479 20. MOBILE NO. 09918084393

15. AGENCY EMPLOYEE NO. 5485753 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)
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME LAYCANO 01/18/1958

SR
FIRST NAME RODOLFO

MIDDLE NAME BALISBISAN

25. MOTHER'S MAIDEN NAME

SURNAME ESMEJARDA 6/2/1961

FIRST NAME FE

MIDDLE NAME FELOMENO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
UNITS ACADEMIC
LEVEL (Write in full) EARNED
GRADUATED
HONORS
(Write in full) (if not RECEIVED
From To
graduated)
Ananias Laico Memorial Elementary
ELEMENTARY
School
Elementary 1996 2001 2001
VOCATIONAL /
SECONDARY Liliw National High School Secondary 2001 2005 2005 Achiever

COLLEGE TRADE ACTS Computer College Bachelor of Science in Information Technology 2005 2009 2009
COURSE
Master of Arts in Physical Education and Sports
GRADUATE STUDIES University of Perpetual Help System Dalta
Management
2021 - 24 units
(Continue on separate sheet if necessary)

SIGNATURE DATE January 5, 2023

CS FORM 212 (Revised 2017), Page 1 of 4

naturalization
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

Civil Service Exam - Professional Level 80.5 PGMNHS

LET 75.0 Enverga University 1265598

(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/ SERVICE
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY PAY GRADE (if STATUS OF
(Write in full/Do (Write SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) in full/Do not abbreviate) INCREMENT
From To
(Y/ N)
2014 to present Teacher I DepEd Laguna - Magdalena INHS 27723.00 11-02 Permanent Y
Municipality of Magdalena - Office of the
2011 2013 Office Staff 5400.00 Contractual Y
Mayor
2009 2010 Selling Clerk SM City Sta. Rosa 6500.00 Contractual N

(Continue on separate sheet if necessary)

SIGNATURE DATE January 5, 2023

CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (Write in
full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

Gawad Laguna INC. 2012 Present Member

(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
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) From To Technical/etc)
DepEd TV Teacher Broadcaster Training Cum Workshop
01/25/2022 01/28/2022 24.0 DepEd Central Office - ICTS
on School on Broadcast: Lesson on Air
Advanced TV Hosting Workshop for Teacher
1/2/2021 1/2/2021 8.0 DepEd Central Office - ICTS
Broadcasters
Core Values Training for DepEd TV Teacher
09/21/2020 09/21/2020 8.0 DepEd Central Office - ICTS
Broadcasters Batch3
Deped TV Teacher Broadcaster Training Batch 3 7/9/2020 9/9/2020 24.0 DepEd Central Office - ICTS

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 33.
(Write in full) (Write in
full)
2022 Outstanding Teacher of the Year - Third Instabright
Computer Literate Gawad Laguna INC
National Awards for Educators
2012 Natatanging Pagkilala - Namumukod-tanging Kabataan
Voice Over Artist
ng Laguna

(Continue on separate sheet if necessary)

SIGNATURE DATE January 5, 2023

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
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 before YES ✘ NO
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 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 TEL. NO.

ID picture taken within
the last 6 months
TEOFILA V. TABULINA MAGDALENA LAGUNA 9173124771 3.5 cm. X 4.5 cm
(passport size)

JUANA A. ARVESU LILIW LAGUNA 9367409663 With full and handwritten

name tag and signature over
printed name
JEANETTE R. MILLENA MAJAYJAY LAGUNA 9073875607
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
is not acceptable
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.

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

PLEASE INDICATE ID Number and Date of
Issuance
Government Issued ID: UMID

ID/License/Passport No.: 021174684555

Signature (Sign inside the box)
January 5, 2023
Date/Place of Issuance:
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