CS Form No. ***
Revised ****
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 Pangalian
NAME EXTENSION (JR., SR)
FIRST NAME Mina
MIDDLE NAME Macabalang
3. DATE OF BIRTH
(mm/dd/yyyy) 05/16/1990 16. CITIZENSHIP
4. PLACE OF BIRTH Pasig City If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Female
17. RESIDENTIAL ADDRESS
6 CIVIL STATUS Married
House/Block/Lot No. Street
unit 406 Isabelle Condominium Hidalgo street
Subdivision/Village Barangay
brgy 383
7. HEIGHT (m) 5'2
City/Municipality Province
8. WEIGHT (kg) 50 kg ZIP CODE Quiapo Manila
18. PERMANENT ADDRESS
9. BLOOD TYPE negative O
House/Block/Lot No. Street
unit 406 Isabelle Condominium Hidalgo Street
10. GSIS ID NO.
Subdivision/Village Barangay
11. PAG-IBIG ID NO. brgy 383
City/Municipality Province
12. PHILHEALTH NO. ZIP CODE Quiapo Manila
13. SSS NO. 19. TELEPHONE NO. N/A
14. TIN NO. 20. MOBILE NO. +639*********
15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) ***************@*****.***
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME Pangalian 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) Norjannah Macabalang Pangalian
FIRST NAME Norodin 11/12/2015
Khadijah Macabalang Pangalian
MIDDLE NAME Diranggoin 6/9/2017
Norfatin Macabalang Pangalian
OCCUPATION self-employed 01/16/2019
EMPLOYER/BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.
24. FATHER'S SURNAME Macabalang
NAME EXTENSION (JR., SR)
FIRST NAME ali
MIDDLE NAME Lambabai
25. MOTHER'S MAIDEN NAME
SURNAME Pitonang
FIRST NAME Amina
MIDDLE NAME Cornell (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
NAME OF SCHOOL HIGHEST LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
LEVEL (Write in BASIC EDUCATION/DEGREE/COURSE UNITS
GRADUATED
ACADEMIC
full) (Write in full) EARNED HONORS
(if not graduated) RECEIVED
From To
ELEMENTARY Pinagbuhatan Elementary School Elementary Education
SECONDARY Pinagbuhatan High School Secondary Education
VOCATIONAL /
TRADE
COURSE Bachelor of Elementary Education Major in
COLLEGE Philippines Muslim Teacher's College General Education 7/6/2014 7/13/2021 2021
GRADUATE STUDIES Master in Public Administration Public Administration 7/13/2021 7/14/2022 2022
(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 EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity
(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 (mm/dd/ SALARY/ JOB/ PAY SERVICE
yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
MONTHLY 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)
(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
(Continue on separate sheet if necessary)
VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
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
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. 33. (Write in
(Write in full) full)
(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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
b. Have you been criminally charged before any court?
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?
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 If YES, give details:
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 (except
Barangay election)?
If YES, give details:
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?
If YES, give details:
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
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?
If YES, please specify:
b. Are you a person with disability?
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
4.5 cm. X 3.5 cm
(passport size)
Computer generated
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 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:
ID/License/Passport No.:
Signature (Sign inside the box)
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