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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 BULAGNIR

FIRST NAME GENWARD NONE

MIDDLE NAME LAMUSAO


3. DATE OF BIRTH
(mm/dd/yyyy) 10/5/1993 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH BRGY. SAN FRANCISCO CATUBIG, N. SAMAR If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female
17. RESIDENTIAL ADDRESS NONE NONE
6 CIVIL STATUS ✘ Single Married
House/Block/Lot No. Street
Widowed Separated N/A RAMA
Other/s: Subdivision/Village Barangay
CATBALOGAN CITY SAMAR
7. HEIGHT (m) 1.69
City/Municipality Province
8. WEIGHT (kg) 56 ZIP CODE 6700
18. PERMANENT ADDRESS NONE NONE
9. BLOOD TYPE A
House/Block/Lot No. Street
NONE CANUCTAN
10. GSIS ID NO. 021-1599-8692-2
Subdivision/Village Barangay
CATUBIG NORHTERN SAMAR
11. PAG-IBIG ID NO. 121126679624
City/Municipality Province

12. PHILHEALTH NO. 03-025655754-8 ZIP CODE 6418

13. SSS NO. 34-4727790-1 19. TELEPHONE NO. NONE

14. TIN NO. 318-914-333 20. MOBILE NO. 09556907511

15. AGENCY EMPLOYEE NO. 6291558 21. E-MAIL ADDRESS (if any) genward.bulagnir@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME NONE 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) NONE
FIRST NAME NONE

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME BULAGNIR

FIRST NAME WILLIAM

MIDDLE NAME GALIT

25. MOTHER'S MAIDEN NAME

SURNAME LAMUSAO

FIRST NAME GEMMA

MIDDLE NAME CUNTAPAY (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND


NAME OF SCHOOL HIGHEST LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
BASIC EDUCATION/DEGREE/COURSE UNITS ACADEMIC
LEVEL (Write in EARNED
GRADUATED
HONORS
(Write in full)
full) (if not graduated) RECEIVED
From To

ELEMENTARY CATUBIG CENTRAL ELEMENTARY SCHOOL PRIMARY EDUCATION 6/4/2004 3/31/2006 GRADUATE 2006 NONE

VOCATIONAL
SECONDARY / CATUBIG VALLEY NATIONAL HIGH SCHOOL HIGH SCHOOL 6/5/2006 4/5/2010 GRADUATE 2010 NONE

FAIR GEMS ACADEMY COMPUTER HARDWARE SERVICING 8/10/2015 ### 6 UNITS 2015 NONE

TRADE
COURSE UNIVERSITY OF EASTERN PHILIPPINES, PEDRO
COLLEGE
REBADULLA MEMORIAL CAMPUS CATUBIG
BACHELOR OF SECONDARY EDUCATION 6/7/2010 3/31/2014 GRADUATE 2014 NONE

GRADUATE STUDIES NONE NONE NONE NONE NONE NONE NONE

(Continue on separate sheet if necessary)

SIGNATURE DATE January 22, 2018

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
PROFESSIONAL BOARD EXAMINATION
75.0 8/17/2014 MANILA 1324105 10/5/2017
FOR TEACHERS

(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
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in (Write in SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
full/Do not abbreviate) full/Do not abbreviate) INCREMENT
From To (Y/
N)
CURRENT ANTONIO G. TUASON NATIONAL HIGH REGULAR-
6/3/2016
DATE
TEACHER-I 19000.00 11-1 YES
SCHOOL CATBALOGAN CITY, SAMAR PERMANENT
BRGY. LENOY AHAN CATUBIG,
2/19/2016 3/31/2016 SUBSTITUTE TEACHER 18549.00 NONE CONTRACTUAL YES
NORTHERN SAMAR
11/25/2014 9/21/2015 RECEIVING AND DISPATCHING UNIT SUPER VALUE INCORPORATION 12000.00 NONE CONTRACTUAL NO
SEASONAL
11/25/2014 11/14/2015 RECEIVING CLERCK RIVERA MERCANTILE SYSTEM INC. 12.000.00 NONE CONTRACUAL
NO

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 22, 2018

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 NONE NONE NONE NONE

(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) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To
FINANCIAL MANAGEMENT OPERATON MANUAL SEMINAR WORKSHOP FOR
11/21/2017 12/1,2017 DEPED CATBALOGAN CITY DIVISION
IMPLEMENTING AND NON-IMPLEMENTING UNITS

REGIONAL DIVISION-BASED TRAINING IN COACHING AND OFFICIATIING 9/3/2017 11/5/2017 24.0 DEPED CATBALOGAN CITY DIVISION

COMPUTER HARDWARE SERVICING NC II 5/1015 10/16/2015 392.0 TECHNICAL-VOCFAIR GEMS ACADEMY

(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)
COACH-SILVER AND BRONZE MEDALIST (2018 EASRERN VISAYAS REGIONAL
WRESTLING NONE
ATHLETIC ASSOCIATION MEET)
VOLLEY BALL NONE NONE

BASKET BALL NONE NONE

CHESS NONE NONE

WUSHU NONE NONE

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 22,2018


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:


________________________________

a. Have you ever been found guilty of any administrative offense? YES ✘ NO
35.

If YES, give details:


________________________________
________________________________
YES ✘ NO
b. Have you been criminally charged before any court?
If YES, give details:
________________________________
Date Filed:
________________________________
Status of Case/s:
YES ✘ NO
36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation
by any court or tribunal?
If YES, give details:
________________________________
YES ✘ NO
________________________________
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? ________________________________
YES ✘ NO
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? YES If YES, give details:
✘ NO

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? YES If YES, give details:
✘ NO

39. Have you acquired the status of an immigrant or permanent resident of another country?
If YES, give details (country):

40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA YES ✘ NO
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?
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
MARVIN ACEDERA CATUBIG, NORTHERN SAMAR 9168522268 3.5 cm. X 4.5 cm
(passport size)

PEPITO ADARAYAN CATUBIG, NORTHERN SAMAR 9262159221 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
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 filing of PHOTO
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.: 1324105


Signature (Sign inside the box)
11/3/2017
Date/Place of Issuance: 11/17/2014 MANILA
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