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 NAVARRETE
NAME EXTENSION (JR., SR)
FIRST NAME MARNIDA

MIDDLE NAME APILADO

3. DATE OF BIRTH

(mm/dd/yyyy)
11/01/1988 16. CITIZENSHIP FILIPINO

4. PLACE OF BIRTH SAN FERNANDO CITY LA UNION If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX FEMALE

6 CIVIL STATUS MARRIED 17. RESIDENTIAL ADDRESS 48 SITIO UBBOG

House/Block/Lot No. Street
PUROK 3 BARAOAS
Subdivision/Village Barangay
7. HEIGHT (m) 1.63 SAN FERNANDO CITY LA UNION
City/Municipality Province
8. WEIGHT (kg) 45 ZIP CODE 2500

9. BLOOD TYPE A+ 18. PERMANENT ADDRESS 48 SITIO UBBOG

House/Block/Lot No. Street
10. GSIS ID NO. NA PUROK 3 BARAOAS
Subdivision/Village Barangay
11. PAG-IBIG ID NO. 1210-0376-2451 SAN FERNANDO CITY LA UNION
City/Municipality Province

12. PHILHEALTH NO. 04-050105128-6 ZIP CODE 2500

13. SSS NO. 01-1877617-4 19. TELEPHONE NO. NA

14. TIN NO. 260-498-635 20. MOBILE NO. 09271457349

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

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME NAVARRETE 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME HERWIN

NAME EXTENSION (JR., SR) KASHMIR ELLINETH A. NAVARRETE 07/08/2013

MIDDLE NAME MENDOZA KHALEN DRAKE EZEKIEL A. NAVARRETE 08/08/2015

OCCUPATION COMMUNITY EMPOWERMENT FACILITATOR KHAILENE AVERY A. NAVARRETE 07/20/2020

EMPLOYER/BUSINESS NAME DSWD

BUSINESS ADDRESS QUEZON AVENUE SAN FERNANDO CITY LA UNION

TELEPHONE NO. 9271632135

24. FATHER'S SURNAME APILADO
NAME EXTENSION (JR., SR)
FIRST NAME REYNALDO

MIDDLE NAME PERALTA

25. MOTHER'S MAIDEN NAME

SURNAME DACUMOS

FIRST NAME NATIVIDAD

MIDDLE NAME MARZO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

SCHOLARSHIP/
26. PERIOD OF ATTENDANCE HIGHEST LEVEL/
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE YEAR ACADEMIC
LEVEL UNITS EARNED
(Write in full) (Write in full) (if not graduated)
GRADUATED HONORS
RECEIVED
From To
BANGBANGOLAN ELEMENTARY
ELEMENTARY PRIMARY 6/17/1995 3/10/2001 2001
SCHOOL
BANGBANGOLAN NATIONAL HIGH
SECONDARY SECONDARY 6/10/2001 3/10/2005 2005
SCHOOL
VOCATIONAL /
TRADE COURSE
NA NA NA NA NA
DON MARIANO MARCOS BACHELOR OF SCIENCE IN
COLLEGE
MEMORIAL STATE UNIVERSITY - OFFICE MANAGEMENT
6/27/2005 3/18/2009 2009
MLUC
GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE August 24, 2023

CS FORM 212 (Revised 2017), Page 1 of 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
(If Applicable) NUMBER Date of

BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity

NA NA NA NA NA NA

(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.
INCLUSIVE DATES SALARY/ JOB/
28. PAY GRADE (if GOV'T
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY STATUS OF
applicable)& SERVICE
(Write in full/Do not abbreviate) (Write in full/Do not abbreviate) SALARY STEP (Format "00 APPOINTMENT (Y/ N)
From To -0")/ INCREMENT

04/16/2023 09/16/2023 TEAM LEADER PUREGOLD PRICE CLUB INC 14000.00 NA PERMANENT N
VASTANA PROPERTIES AND
02/03/2022 02/10/2023 REAL ESTATE ACCOUNT EXECUTIVE 20000.00 NA CONTRACTUAL N
DEVELOPMENT CORPORATION
07/01/2011 11/10/2012 APPRAISER / VAULT CUSTODIAN BHF PAWNSHOP
8000.00 NA PERMANENT N
METROBANK MAIN LA UNION
07/10/2009 05/10/2011 HANDLER / SORTER 12000.00 NA CONTRACTUAL N
BRANCH
06/01/2009 07/10/2009 STORES CASHIER SM BAGUIO 10000.00 NA PERMANENT N
 (Continue on separate sheet if necessary)

SIGNATURE DATE August 24, 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
From To

CHILD DEVELOPMENT CENTER- BARAOAS SAN FERNANDO CITY LA UNION 6/15/2017 3/15/2018 NA SCHO

BANGBANGOLAN ELEMENTARY SCHOOL - GOVERNANCE COUNCIL

8/14/2022 8/15/2023 NA SCHOOL GOVERNA
PRESIDENT

(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 Type of LD

30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE ( Managerial/
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/

Technical/etc)
From To
LAS
REAL ESTATE SERVICE TRAINING PROGRAM 08/18/2022 08/20/2022 24.0 TECHNICAL

JOB PLACEMENT SEMINAR 02/2009 02/2009 8.0 MANAGERIAL DMM

DEVELOPING AND MAINTAINING QUALITY IN OFFICE MANAGEMENT 02/11/2009 02/12/2009 16.0 MANAGERIAL DMM
ON THE JOB - TRAINING DMMMSU ADMINISTRATIVE/PERSONNEL RECORD
06/10/2008 11/10/2008 300.0 TECHNICAL DMM
SECTION
ON THE JOB - TRAINING DEPARTMENT OF HEALTH 11/2007 02/2008 200.0 MANAGERIAL DEPAR

MICROSOFT APPLICATION TRAINING 10/2007 10/2007 20.0 TECHNICAL N

FIRST AID SEMINAR - BASIC LIFE SUPPORT TRAINING 09/29/2007 09/29/2007 8.0 TECHNICAL DMM

ON THE JOB TRAINING - DMMMSU ALUMNI 11/2006 04/2007 200.0 MANAGERIAL DMM
OFFICE MANAGEMENT COMPETENCY ENHANCEMENT SEMINAR
11/11/2005 11/11/2005 8.0 MANAGERIAL DMM
WORKSHOP

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMB
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

COMMUNICATION
NA OFFICE

PLANNING

SOCIAL SKILLS

STORES OPERATION & MANAGEMENT

MICROSOFT APPLICATION
GARDENING

FARMING
(Continue on separate sheet if necessary)

SIGNATURE DATE
N / NATURE OF WORK

OOL TREASURER

ANCE COUNCIL PRESIDENT

CONDUCTED/ SPONSORED BY
(Write in full)

S PIÑAS CITY REAL ESTATE

INCORPORATED
MMSU MID LA UNION CAMPUS

MMSU MID LA UNION CAMPUS

MMSU MID LA UNION CAMPUS

RTMENT OF HEALTH REGION 1

NETOPIA INTERNET CAFE

MMSU MID LA UNION CAMPUS

MMSU MID LA UNION CAMPUS

MMSU MID LA UNION CAMPUS

BERSHIP IN ASSOCIATION/ORGANIZATION
(Write in full)

E MANAGEMENT ASSOCIATION
August 24, 2023
CS FORM 212 (Revised 2017), Page 3 of 4
 34. Are you related by consanguinity or affinity to the appointing or recommending
chief of bureau or office or to the person who has immediate supervision over you in
Bureau or Department where you will be apppointed,
a. within the third degree? NO
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 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, retirement, dropped from the rolls, dismissal, termination, end of term, If YES, give details: ________________________________
finished contract or phased out (abolition) in the public or private sector? RESIGNATION
38. a. Have you ever been a candidate in a national or local election held within the last NO
year (except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period 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 NO
country?
If YES, give details (country):

40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled NO
Persons (RA 7277); and (c) Solo Parents Welfare Act of 2000 (RA 8972), please answer
a. the following items:
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)

ID picture taken within

NAME ADDRESS TEL. NO. the last 6 months

3.5 cm. X 4.5 cm

(passport size)


ROMMEL ECOLIN AGOO LA UNION 9178378536
With full and handwritten

name tag and signature over

GEORGETTE GUMANGAN SAN FERNANDO CITY LA UNION 9270695957 printed name

Computer generated

LEA DEL ROSARIO CANDON ILOCOS SUR 9995710290 or photocopied picture

is not acceptable

42. 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 PHOTO
document and its attachments shall cause the 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: DRIVERS LICENSE

ID/License/Passport NoA04-17-000859
Signature (Sign inside the box)

Date/Place of Issuance:LTO REGION 1

Date Accomplished Right Thumbmark

UBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated ab
Person Administering Oath

CS FORM 212 (Revised 2017), Page 4 o

bov
of 4
Yes/No Cstat Gender
Yes Single Male
No Married Female
Separated
Widowed