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 SAURE
FIRST NAME YVONE NAME EXTENSION (JR., SR) N/A
MIDDLE NAME POSIDIO
3. DATE OF BIRTH
(mm/dd/yyyy) 16. CITIZENSHIP
9/2/1995 ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH SANGBAY, NAGTIPUNAN, QUIRINO If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX
Male ✘ Female
6 CIVIL STATUS
17. RESIDENTIAL ADDRESS PUROK 2 N/A
Single ✘ Married House/Block/Lot No. Street
Widowed Separate N/A SANGBAY
Other/s: d Subdivision/Village Barangay
7. HEIGHT (m) 1.54 NAGTIPUNAN QUIRINO
City/Municipality Province
8. WEIGHT (kg) 63 ZIP CODE 3405
9. BLOOD TYPE O
18. PERMANENT ADDRESS PUROK 2 N/A
House/Block/Lot No. Street
10. GSIS ID NO. NONE N/A SANGBAY
Subdivision/Village Barangay
11. PAG-IBIG ID NO. 1212-7460-6173 NAGTIPUNAN QUIRINO
City/Municipality Province
12. PHILHEALTH NO. 06-025309920-0 ZIP CODE 3405
13. SSS NO. 01-2667374-8 19. TELEPHONE NO. NONE
14. TIN NO. 485-773-571 20. MOBILE NO. 0912-9062-637
15. AGENCY EMPLOYEE NO. NONE 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME SAURE 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) N/A
FIRST NAME EDZEL JOSEPH YVANA EDZELA P.SAURE 2/20/2023
MIDDLE NAME MIGUEL
OCCUPATION PUBLIC SCHOOL TEACHER
EMPLOYER/BUSINESS NAME DEPARTMENT OF EDUCATION-SDO QUIRINO
BUSINESS ADDRESS GUNDAWAY, CABARROGUIS, QUIRINO
TELEPHONE NO. 0963-0244-206
24. FATHER'S SURNAME POSIDIO
FIRST NAME LEONARDO NAME EXTENSION (JR., SR) N/A
MIDDLE NAME SANTOS
25. MOTHER'S MAIDEN NAME
SURNAME SARMIENTO
FIRST NAME GINA
MIDDLE NAME VALERA (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
HIGHEST LEVEL/
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE
UNITS
YEAR
SCHOLARSHIP/ ACADEMIC
LEVEL (Write (Write in full) GRADUATE HONORS RECEIVED
in full) EARNED
D
(if not graduated)
From To
ELEMENTARY SANGBAY INTEGRATED SCHOOL ELEMENTARY 2001 2006 GRADUATED 2006 SPECIAL AWARD
VOCATIONAL
SECONDARY / SANGBAY INTEGRATED SCHOOL SECONDARY 2006 2011 GRADUATED 2011 TOP 6
NONE N/A N/A N/A N/A N/A N/A
TRADE
COURSE BACHELOR OF SECONDARY
COLLEGE QUIRINO STATE UNIVERSITY EDUCATION MAJOR IN 2012 2016 GRADUATED 2016 NONE
TECHNOLOGY AND LIVELIHOOD
EDUCATION
MASTER OF ARTS IN EDUCATION
GRADUATE STUDIES QUIRINO STATE UNIVERSITY MAJOR IN ADMINISTRATION AND 2024 PRESENT
MANAGEMENT
(Continue on separate sheet if necessary)
SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER RATING DATE OF
SPECIAL LAWS/ CES/ CSEE (If Applicable) EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT NUMBER Date of
Validity
TEACHER'S LICENSURE EXAMINATION 82.60 9/1/2022 CAUAYAN CITY 2050285 9/2/2026
********** NOTHING FOLLOWS **********
(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 SERVICE
28. INCLUSIVE DATES SALARY/ JOB/ PAY
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY GRADE (if STATUS OF
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To (Y/ N)
6/2016 12/2016 INSTRUCTIONAL MANAGER DEPARTMENT OF EDUCATION/ ALTERNATIVE 8000.00 CONTRACTOF SERVICE Y
LEARNING SYSTEM
8/1/2018 10/1/2018 BRANCH SECRETARY/ CASHIER EQUITY MOTORCYCLES INC. 8000.00 REGULAR PERMANENT N
8/5/2019 5/15/2022 ELEMENTARY TEACHER SAINT VINCENT SCHOOL 12000.00 CONTRACT OF SERVICE N
1/15/2025 PRESENT TEACHER AIDE MACABO ELEMENTARY SCHOOL CONTRACT OF SERVICE Y
*********** NOTHING FOLLOWS **********
(Continue on separate sheet if necessary)
SIGNATURE DATE
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 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
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE Type of LD
NUMBER OF HOURS
( Managerial/ CONDUCTED/ SPONSORED BY
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To
NONE N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. NON-ACADEMIC DISTINCTIONS / RECOGNITION (Write in full) 33. (Write in
full)
TEACHING NONE NONE
COMPUTER SKILLS
********** NOTHING FOLLOWS **********
(Continue on separate sheet if necessary)
SIGNATURE DATE
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
✘
b. within the fourth degree (for Local Government Unit - Career Employees)? YES
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
by any court or tribunal? YES ✘ 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 YES ✘ NO
out (abolition) in the public or private sector? If YES, give details:
________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? YES ✘ NO
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last YES
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?
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: AYANGAN
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
EUFEMIA L. PARAGAS PINARIPAD NORTE, AGLIPAY, 9155105420
the last 6 months
QUIRINO 3.5 cm. X 4.5 cm
(passport size)
With full and handwritten
name tag and signature over
printed name
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
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable
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. PHOTO
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.: 2050289 Signature (Sign inside the box)
Date/Place of Issuance: 5/24/2023/SANTIAGO 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
