CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misinterpretation 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 DELA FUERTA
NAME EXTENSION (JR., SR)
FIRST NAME IRISH MELODY

MIDDLE NAME BUYAN

3. DATE OF BIRTH
(mm/dd/yyyy) 12/23/1995 16. CITIZENSHIP

4. PLACE OF BIRTH P-2 BRGY. MARCOS, MAGALLANES, AGUSAN DEL NORTE If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX

17. RESIDENTIAL ADDRESS P-6

6 CIVIL STATUS
House/Block/Lot No. Street
STO.NINO
Subdivision/Village Barangay
MAGALLANES AGUSAN DEL NORTE
7. HEIGHT (m) 1.54
City/Municipality Province
8. WEIGHT (kg) 51 ZIP CODE 8604

18. PERMANENT ADDRESS P-6

9. BLOOD TYPE A+
House/Block/Lot No. Street
STO.NINO
10. GSIS ID NO. ON PROCESS
Subdivision/Village Barangay
MAGALLANES AGUSAN DEL NORTE
11. PAG-IBIG ID NO. 1211-4773-3464
City/Municipality Province

12. PHILHEALTH NO. 18-250286663-0 ZIP CODE 8604

13. SSS NO. 08-2572200-0 19. TELEPHONE NO. 806-0288

14. TIN NO. 469-400-480 20. MOBILE NO. 09454573524/ 09489677968

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) irishmelody.buyan@deped.gov.ph
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME DELA FUERTA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) HAILEY PSYCHE B. DELA FUERTA
FIRST NAME ERLE CHRISTIAN 7/7/2018
GEORGE ZOEY B. DELA FUERTA
MIDDLE NAME ZAPICO 9/7/2019

OCCUPATION SK CHAIRPERSON

EMPLOYER/BUSINESS NAME BRGY. CALOC-AN

BUSINESS ADDRESS MAGALLANES, AGUSAN DEL NORTE

TELEPHONE NO. NONE

24. FATHER'S SURNAME RAMOS

NAME EXTENSION (JR., SR)
FIRST NAME EDWIN

MIDDLE NAME GONGORA

25. MOTHER'S MAIDEN NAME

SURNAME BUYAN

FIRST NAME NORMELA

MIDDLE NAME HERIZO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST
NAME OF SCHOOL 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 RECEIVED
From To graduated)

ELEMENTARY MAGALLANES NORTH ELEMENTARY SCHOOL ELEMENTARY 2001 2007 GRADUATED 2007 FIRST H.M

SECONDARY /
VOCATIONAL MAGALLANES NATIONAL HIGH SCHOOL SECONDARY 2007 2011 GRADUATED 2011 SIXTH H.M

TRADE
COURSE PHILIPPINE NORMAL UNIVERSITY-MINDANAO BACHELOR OF SECONDARY EDUCATION DEANS
COLLEGE
CAMPUS -MAJOR IN PHYSICAL EDUCATION
2011 2015 GRADUATED 2015
LISTER

GRADUATE STUDIES SAINT JOSEPH INSTITUTE OF TECHNOLOGY MASTER OF ARTS IN EDUCATION(MAED) 2017 PRESENT

(Continue on separate sheet if necessary)

SIGNATURE DATE 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

LET ( LICENSURE EXAMINATION FOR TEACHERS) 76.4 09/27/2015 CAGAYAN DE ORO CITY 1415950 12/23/2022

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

1/6/2018 PRESENT TEACHER I MAGALLANES NATIONAL HIGH SCHOOL 20,754 11 PERMANENT YES

8/8/2017 4/4/2018 TEACHER I NASIPIT NATIONAL VOCATIONAL SCHOOL 19, 620 11 PERMANENT YES
GRADE 4 ADVISER, HIGH SCHOOL PROBATIONA
1/6/2015 03/31/2017 ENFANT CHERI STUDY CENTRE, INC. 11200.00 0-0 NO
SUBJECT TEACHER RY

(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

MAGALLANES ATHLETIC ASSOCIATION (MAA) 1/6/2018 PRESENT MEMBER

(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) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To

THREE-DAY LIVE IN TRAINING FOR MUSIC AND ARTS 08/23/18 08/25/18 24.0 AMONTAY BEACH RESORT

21ST CARAGA REGIONAL ATHLETIC MEET (CRAM) 08/24/17 08/26/17 24.0 TECHNICAL BAROBO, SURIGAO DEL SUR

SIP WORKSHOP & SEMINAR 9/4/2017 9/6/2017 27.0 NASIPIT, AGUSAN DEL NORTE

ALS BOOKKEEPING COURSE 9/7/2016 12/17/2016 90.0

RAFAELITO B. CACHUELA

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33. ASSOCIATION/ORGANIZATION
(Write in full)
(Write in full)

CBI(CHRISTIAN BROTHERHOOD
PLAYING VOLLEYBALL N/A
INTERNATIONAL)
BOOKKEEPING

SWIMMING

SINGING

DANCING

PHOTOJOURNALIST

DRESSMAKING
(Continue on separate sheet if necessary)

SIGNATURE DATE CS FORM 212 (Revised 2017), Page 3 of 4

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? ________________________________
FINISHED CONTRACT
________________________________
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
P-5 BRGY. STO.NINO, MAGALLANES, the last 6 months
FLORANTE A. MORE AGUSAN DEL NORTE
09474434542 3.5 cm. X 4.5 cm
(passport size)
BRGY. BUHANG, MAGALLANES, AGUSAN
ABIGAIL R. GERONG DEL NORTE
09204700841 With full and handwritten
name tag and signature over
B3 L43 TOWN SUBD. LIBERTAD, BUTUAN printed name
MEDELENE AMANTE CITY
09195199648
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete or photocopied picture
is not acceptable
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 PHOTO
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/License/Passport No.: 1415950

Signature (Sign inside the box)

Date/Place of Issuance: 12/21/2015, BUTUAN CITY

Date Accomplished Right Thumbmark

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

MARIA CORAZON C. PLASABAS

ADMINISTRATIVE OFFICER V
Person Administering Oath

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