CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misrepresentation 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 EJAUS
NAME EXTENSION (JR., SR) N/A
FIRST NAME RUFFA MAE

MIDDLE NAME APONGOL

3. DATE OF BIRTH
(mm/dd/yyyy) 8/2/1997 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH CANDELARIA, ZAMNBALES If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

Single ✘ Married 17. RESIDENTIAL ADDRESS PUROK 4B

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
UACON
Other/s:
Subdivision/Village Barangay
CANDELARIA ZAMBALES
7. HEIGHT (m) 5"
City/Municipality Province
8. WEIGHT (kg) 45kg ZIP CODE 2212
18. PERMANENT ADDRESS PUROK 4B
9. BLOOD TYPE A+
House/Block/Lot No. Street
UACON
10. GSIS ID NO. N/A
Subdivision/Village Barangay
CANDELARIA ZAMBALES
11. PAG-IBIG ID NO. 1212-2678-4170
City/Municipality Province
12. PHILHEALTH NO. 02027087783 ZIP CODE 2212

13. SSS NO. 34-7617025-7 19. TELEPHONE NO. N/A

14. TIN NO. 347-161-622-000 20. MOBILE NO. 0916-591-2460

15. AGENCY EMPLOYEE NO. 50000178 21. E-MAIL ADDRESS (if any) [email protected]

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME EJAUS 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME OLIVER N/A GAENBURH ZYONN A. EJAUS 7/8/2022

MIDDLE NAME EDQUIBAL

OCCUPATION TEACHER

EMPLOYER/BUSINESS NAME SAN ANDRES SCHOOL OF MASINLOC, INC

BUSINESS ADDRESS SOUTH POBLACION, MASINLOC, ZAMBALES

TELEPHONE NO. 047-307-5010

24. FATHER'S SURNAME APONGOL

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

MIDDLE NAME ANINAG

25. MOTHER'S MAIDEN NAME

SURNAME MANANSALA

FIRST NAME SHIRLEY

MIDDLE NAME EDQUILANG (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)
ELEMENTARY UACON ELEMENTARY SCHOOL ELEMENTARY EDUCATION 2003 2009 GRADUATED 2009 N/A
VOCATIONAL /
SECONDARY LAUIS NATIONAL HIGH SCHOOL SECONDARY EDUCATION 2009 2013 GRADUATED 2013 N/A

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

COLLEGE TRADE NORTHERN ZAMBALES COLLEGE BACHELOR OF ELEMENTARY EDUCATION 2014 2018 GRADUATED 2018 CHED
COURSE

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

(Continue on separate sheet if necessary)

SIGNATURE DATE MAY 12, 2023

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 75.6 03/24/2019 MANILA 1768729 8/2/2025

(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 SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To
(Y/ N)
SAN ANDRES SCHOOL OF MASINLOC,
3/6/2019 PRESENT TEACHER 11000.00 N/A N/A N/A
INC.

(Continue on separate sheet if necessary)

SIGNATURE DATE MAY 12, 2023

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 NUMBER OF
(Write in full) (mm/dd/yyyy) 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
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. NUMBER OF ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS HOURS Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) From To Technical/etc)

ASSOCIATION OF THE CATHOLIC OF THE CATHOLIC SCHOOL

AFFIRMED, AFFIRE TO EVANGELIZE THE YOUNG 02/20/2020 02/20/2020 8 MANAGERIAL OF THE DIOCESE OF IBA
ASSOCIATION OF THE CATHOLIC OF THE CATHOLIC SCHOOL
CURRICULUM MAPPING AND CRITIQUING 9/12/2019 10/12/2019 16 MANAGERIAL OF THE DIOCESE OF IBA
PRIVATE EDUCATIONAL ASSISTANCE COMMITTEE AND
ADEPT WEBINAR 07/14,21/2021 07/28/2021 24 MANAGERIAL NATIONAL TEACHERS COLLEGE

FOOD AND BEVERAGE NC II 2/3/2021 04/14/2021 356 MANAGERIAL SAN ANDRES SCHOOL OF MASINLOC, INC.

NEW METHODS IN NEW EXPRESSIONS: EFFECTIVE

TEACHING STRATEGIES IN THE NEW NORMAL
11/03.2020 3/11/2020 2 MANAGERIAL CATHOLIC EDUCATIONAL ASSOCIATION OF THE PHILIPPINES

PLEASE BE CAREFUL WITH YOUR ART: OBSERVE

CULTURAL & GENDER SENSITIVITY AND RESPECT FOR 10/22/2020 10/22/2020 2 MANAGERIAL CATHOLIC EDUCATIONAL ASSOCIATION OF THE PHILIPPINES
INTELLECTUAL PROPERTY IN MODULE MAKING

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES (Write in 33.
(Write in full)
full)

SINGING N/A N/A

DANCING N/A N/A

COMPUTER LITERATE N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE MAY 12, 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:
________________________________
N/A

35. a. Have you ever been found guilty of any administrative offense? YES ✘ NO
If YES, give details:
________________________________
N/A
________________________________
b. Have you been criminally charged before any court? YES ✘ NO
If YES, give details:
________________________________
Date Filed: N/A
________________________________
Status of Case/s: N/A

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:
________________________________
N/A
________________________________
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? ________________________________
N/A
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year
YES ✘ NO
(except Barangay election)? N/A
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: N/A
39. Have you acquired the status of an immigrant or permanent resident of another country?
YES ✘ NO
If YES, give details (country):
N/A
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: N/A
b. Are you a person with disability? YES ✘ NO
If YES, please specify ID No: N/A
c. Are you a solo parent? YES ✘ NO
If YES, please specify ID No: N/A

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAME ADDRESS CP NO.

ID picture taken within
UACON, CANDELARIA, the last 6 months
JANE C. MANZANERO ZAMBALES
9998887279 3.5 cm. X 4.5 cm
(passport size)

KARLA JEAN E. ELAMPARO TALTAL, MASINLOC ZAMBALES 9701870059 With full and handwritten
name tag and signature over
SITIO PANGLIT, SAN LORENZO , printed name
MINERVA M. GONZALES MASINLOC, ZAMBALES
9513364143
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: PRC ID

ID/License/Passport No.: 1768729

Signature (Sign inside the box)
MAY 12, 2023
Date/Place of Issuance: 06/11/1019
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this MAY 12, 2023 , affiant exhibiting his/her validly issued government ID as indicated above.

Person Administering Oath

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