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 DALANDA
NAME EXTENSION (JR., SR)
FIRST NAME TOMMY

MIDDLE NAME PASANDALAN

3. DATE OF BIRTH
(mm/dd/yyyy) 10/20/1993 16. CITIZENSHIP

4. PLACE OF BIRTH LUMAYONG, KAYAGA, KABACAN, COTABATO If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX

17. RESIDENTIAL ADDRESS

6 CIVIL STATUS
House/Block/Lot No. Street
LUMAYONG KAYAGA
Subdivision/Village Barangay
KABACAN COTABATO
7. HEIGHT (m) 1.65
City/Municipality Province
8. WEIGHT (kg) 55 ZIP CODE 9407

18. PERMANENT ADDRESS

9. BLOOD TYPE 0+
House/Block/Lot No. Street
LUMAYONG KAYAGA
10. GSIS ID NO.
Subdivision/Village Barangay

11. PAG-IBIG ID NO. KABACAN COTABATO

City/Municipality Province

12. PHILHEALTH NO. ZIP CODE 9407

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 20. MOBILE NO. 09057304456

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

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME DALANDA

NAME EXTENSION (JR., SR)
FIRST NAME KUKA

MIDDLE NAME SAMBABAY

25. MOTHER'S MAIDEN NAME PASANDALAN

SURNAME DALANDA

FIRST NAME AISA

MIDDLE NAME ANSING (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST LEVEL/ SCHOLARSHIP/
26. NAME OF SCHOOL PERIOD OF ATTENDANCE YEAR
LEVEL (Write in BASIC EDUCATION/DEGREE/COURSE
(Write in full)
UNITS
GRADUATED
ACADEMIC
HONORS
full) EARNED
(if not graduated) RECEIVED
 HIGHEST LEVEL/ SCHOLARSHIP/
NAME OF SCHOOL YEAR
LEVEL (Write in BASIC EDUCATION/DEGREE/COURSE
(Write in full)
UNITS
GRADUATED
ACADEMIC
HONORS
full) EARNED
(if not graduated) RECEIVED
From To 4TH
HONORABL
ELEMENTARY USM CED - INTEGRATED LABORATORY SCHOOL 6/4/2001 4/3/2007 2007 E MENTION
AND BEST
5TH
IN MATH
HONORABL
SECONDARY LUMAYONG HIGH SCHOOL 6/4/2007 3/26/2011 2011 E MENTION
VOCATIONAL /
AND BEST
IN MATH

TRADE
COURSE
COLLEGE UNIVERSITY OF SOUTHERN MINDANAO BACHELOR OF SECONDARY EDUCATION 6/13/2011 4/11/2015 2015

GRADUATE STUDIES

(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

LET(LICENSURE EXAMINATION FOR TEACHER 0.8 9/27/2015 DAVAO CITY 1427809 11/30/2015

(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
(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)

6/1/2015 3/31/2017 CLASSROOM TEACHER ASIAN COLLEGES AND TECHNOLOGICAL 5000.00 500/A.Y N
INSTITUTE INC.
 (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
(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
PHILIPPINE ASSOCIATION FOR TEACHER EDUCATON (PAFTE) XII REGIONAL STUDENTS 3/4/2015 3/4/2015 10.0 PAFTE XII
CONGRESS 2015

JOB INFORMATION SEMINAR 11/14/2014 11/14/2014 10.0

USM OSA AND USM GUIDANCE CENTER
RESEARCH FORUM AND PADTUDLO SEMINAR 2013: HARNESSING THE RESEARCH 9/21/2013 9/21/2013 10.0
COMPETENCIES OF FUTURE K+12 TEACHERS USM CED
SEMINAR-WORKSHOP ON THESIS WRITING AND RESEARCH ETHICS 9/30/2014 9/30/2014 10.0
USM CED SECONDARY DEPARTMENT
,UNIVERSITY OF SOUTHERN MINDANAO PHILIPPINE STATISTICS QUIZ 2013 9/14/2013 9/14/2013 5.0
USM CAS DEPARTMENT OF MATH
SEMINAR WORKSHOP ON STRESS MANAGEMENT 8/9/2013 8/9/2013 10.0
UNIVERSITY GUIDANCE CENTER

(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)

PLAYING SEPAK TAKRAW UNIVERSITY MATHEMATICS SOCIETY

BASIC COMPUTER OPERATION

(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 w
the last 6 mont
JUKAIDA PANDAY KAYAGA, KABACAN, COTABATO 9187649412 3.5 cm. X 4.5 c
(passport size

KAUTIN S. KULANO Ph. D KAYAGA, KABACAN, COTABATO 9091914837 With full and handw
name tag and signat
printed name
LEORENCE TANDOG Ph. D POBLACION, KABACAN, COTABATO 9173347872
Computer genera
42. or photocopied pic
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.

is not acceptab

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.: 1427809

Signature (Sign inside the box)

Date/Place of Issuance: 01/05/2016 DAVAO CITY

Date Accomplished Right Thumbm
SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated

Person Administering Oath

CS FORM 212 (Revi

___________
___________

___________
___________

___________
___________

___________
___________

___________
___________

untry):

Maguindanaun

ID picture taken within

the last 6 months
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten

name tag and signature over
printed name

Computer generated
or photocopied picture
is not acceptable

PHOTO
Right Thumbmark
ernment ID as indicated above.

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