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 SOLOMON
NAME EXTENSION (JR., SR)
FIRST NAME ERICKA
MIDDLE NAME MARCOS
3. DATE OF BIRTH
(mm/dd/yyyy) MARCH 03, 2023 16. CITIZENSHIP

4. PLACE OF BIRTH SAN CARLOS CITY, PANGASINAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX

6 CIVIL STATUS
17. RESIDENTIAL ADDRESS #114
House/Block/Lot No. Street
TURAC
Subdivision/Village Barangay
7. HEIGHT (m) 163 cm SAN CARLOS CITY PANGASINAN
City/Municipality Province
8. WEIGHT (kg) 47 ZIP CODE 2420

9. BLOOD TYPE O
18. PERMANENT ADDRESS # 114
House/Block/Lot No. Street
10. GSIS ID NO. N/A TURAC
Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A SAN CARLOS CITY PANGASINAN

City/Municipality Province

12. PHILHEALTH NO. 05-253732321-3 ZIP CODE 2420

13. SSS NO. 02-5013695-7 19. TELEPHONE NO. N/A

14. TIN NO. N/A 20. MOBILE NO. +639812385925

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) erickasolomon370@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME N/A N/A

MIDDLE NAME

OCCUPATION N/A
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME SOLOMON
NAME EXTENSION (JR., SR)
FIRST NAME ERNESTO
MIDDLE NAME BANAAG
25. MOTHER'S MAIDEN NAME

SURNAME MARCOS
FIRST NAME MELBA
MIDDLE NAME DATUIN (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

WITH
ELEMENTARY TURAC ELEMENTARY SCHOOL BASIC EDUCATION CURRICULUM 3/6/2006 03/27/2012 N/A 2012 HONORS

06/03/2013 03/30/2016 2016 WITH HONORS

TURAC NATIONAL HIGH SCHOOL
SECONDARY K to 12 CURRICULUM N/A WITH
TURAC SENIOR HIGH SCHOOL 06/03/2017 04/19/2018 HIGH HONORS
VOCATIONAL / 2018

N/A N/A N/A N/A N/A N/A N/A

TRADE
PANGASINAN STATE UNIVERSITY - BACHELOR OF SECONDARY WITH
COURSE
COLLEGE 08/26/2019 08/31/2023 N/A 2023
BAYAMBANG CAMPUS EDUCATION - SCIENCE DISTINCTION

GRADUATE STUDIES N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE October 4, 2023

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

(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)

01/17/2019 05/24/2019 CASHIER INGRID MINI CONVENIENT STORE 1700.00 CONTRACTUAL

CITY HEALTH OFFICE - SAN CARLOS CITY, WORK

8/21/2018 11/21/2018 MEDICAL ASSISSTANT
PANGASINAN EMMERSION
01/19/2023 06/30/2023 STUDENT ASISSTANT STUDENT SERVICE OFFICE 200.00 CONTRACTUAL
DUMPAY NATIONAL HIGH SCHOOL
PRE-SERVICE
9/3/2023 06/16/2023 STUDENT TEACHER PSU-BC
TRAINING
LABORATORY INTEGRATED HIGH SCHOOL

(Continue on separate sheet if necessary)

SIGNATURE DATE October 4, 2023

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

PHILIPPINCE CONSORTIUM FOR SCIENCE, MATHEMATICS AND TECHNOLOGY 08/26/2019 08/31/2023 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/
NUMBER OF HOURS CONDUCTED/ SPONSORED BY (Write in full)
(Write in full) (mm/dd/yyyy) Supervisory/
Technical/etc)
From To
PCSMT MOVING FORWARD: ADDRESSING THE CHALLENGES OF STUDENTS DURING THE
10/24/2019 10/25/2019 2 DAY PCSMT
NEW NORMAL

REVISITING PHILIPPINE ETHNOASTRONOMY AMIDST THE PANDEMIC 02/21/2022 02/22/2022 2 DAY

DOST PAGASA

ETHNOASTRONOMY IN THE PHILIPPINES 1/10/2021 1/10/2021 1 DAY DOST PAGASA

HOW TO SPEAK CONFIDENTLY IN PUBLIC EVEN IF YOURE SHY AND INTROVERTED 04/26/2021 04/26/2021 1 DAY SHA NACINO AND THE 90 DAY SPEAK TO THRIVE CHALLENGE

DIPLOMA, OPTIONS, DIRECTION: BEST CAREER OPPORTUNITIES AFTER GRADUATION 06/28/2022 06/28/2022 1 DAY CAST ABEL BAYAMBANG CAMPUS

SEMINAR AND WORKSHOP TRAINING ON CREATIVE PEDAGOGY IN TEACHING 1/8/2023 1/8/2023 1 DAY STUDENT SERVICE LEARNING AND DEVELOPMENT

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

3
NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. 3
(Write in full) (Write in full)
.
3RD PLACE NATIONAL ESSSAY WRITING COMPETITION IN NATIONAL SCIENCE AND
WRITTEN SKILLS N/A
MATHEMATICS WEEK 2021
COMMUNICATION SKILLS 2ND PLACE DAGLIANG TALUMPATI N/A

DRAWING SKILLS MEMBER AND AUDITOR OF VISUALIZTAS ART GROUP IN BAYAMBANG PANGASINAN AUDITOR

SINGING NATIONAL CHOIR FINALIST IN ANTIPOLO RIZAL TAGISAN NG TALENTO

LETTER CUTTING

GARDENING 1ST PLACE IN DISH GARDENING GROUP CATEGORY N/A

COOKING
(Continue on separate sheet if necessary)

SIGNATURE DATE October 4, 2023

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
3.5 cm. X 4.5 cm
DR. DENNIS V. MONTOYA ASSOC. PROF. II OSMENA BASISTA, PANGASINAN (passport size)

With full and handwritten

KRISTEL MAY A. SARZADILLA, MT II MANGATAREM PANGASINAN 9985526159 name tag and signature over
printed name

CHIKKI MAE QUEVEDO, TEACHER II CHICAGO, ILLINOIS USA 9178074590 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 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:

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