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 BERNARDINO
NAME EXTENSION (JR., SR) N/A
FIRST NAME GRACE

MIDDLE NAME NOLASCO

3. DATE OF BIRTH
(mm/dd/yyyy) 09/27/1994 16. CITIZENSHIP
✘ Filipino Dual Citizenship
✘ by birth
by
naturalization
4. PLACE OF BIRTH Dist VIII Cuyapo,Nueva Ecija If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS 029 AROMIN ST.
Widowed House/Block/Lot No. Street
Separated N/A DISTRICT.8
Other/s:
Subdivision/Village Barangay

7. HEIGHT (m) 1.52m CUYAPO NUEVA ECIJA

City/Municipality Province
8. WEIGHT (kg) 60KG ZIP CODE 3117
18. PERMANENT ADDRESS 029 AROMIN ST.
9. BLOOD TYPE O+
House/Block/Lot No. Street
N/A DISTRICT 8
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 12-119856157-6 CUYAPO NUEVA ECIJA

City/Municipality Province
12. PHILHEALTH NO. 07-025852630-7 ZIP CODE 3117

13. SSS NO. 02-4148583-7 19. TELEPHONE NO. N/A

14. TIN NO. 701-859-087-000 20. MOBILE NO. 0935-684-1189
15. AGENCY EMPLOYEE NO.
N/A
21. E-MAIL ADDRESS (if any) bernardinograce9@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) N/A N/A
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME BERNARDINO

NAME EXTENSION (JR., SR) N/A
FIRST NAME GUARLITO

MIDDLE NAME CARBONEL

25. MOTHER'S MAIDEN NAME

SURNAME BERNARDINO

FIRST NAME LUCILA

MIDDLE NAME NOLASCO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST
LEVEL/ SCHOLARSHIP/
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE
UNITS
YEAR
ACADEMIC
LEVEL (Write in full) GRADUATED HONORS
(Write in full) EARNED
(if not RECEIVED
From To
graduated)
ELEMENTARY CUYAPO CENTRAL SCHOOL PRIMARY EDUCATION 2002 2008 2008 N/A
VOCATIONAL
SECONDARY / CUYAPO NATIONAL HIGH SCHOOL HIGH SCHOOL 2008 2012 2012 N/A

N/A

TRADE
COLLEGE
COURSE CIT COLLEGES PANIQUI, TARLAC INC. BACHELOR OF SECONDARY EDUCATION 2012 2016 2016 N/A
Major in English
GRADUATE STUDIES N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE April 1, 2024

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

LICENSURE EXAMINATION FOR TEACHERS 79.0 3/25/2017 ROSALES, PANGASINAN 1544330 09/27/2023

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

08/30/2023 Present MUNICIPAL LOCAL SCHOOL BOARD BUED- LUNA HIGHSCHOOL 4000.00 N/A JOB ORDER YES
TEACHER
ST.PAUL COLLEGES FOUNDATION PANIQUI,
08/22/2022 10/6/2023 JUNIOR HIGH SCHOOL TEACHER TARLAC,INC.
8000.00 N/A CONTRACTUAL NO

09/13/2021 2/7/2022 JUNIOR HIGH SCHOOL TEACHER ST.PAUL COLLEGES FOUNDATION PANIQUI, 8000.00 N/A CONTRACTUAL NO
TARLAC,INC.
ST.PAUL COLLEGES FOUNDATION PANIQUI,
3/6/2019 04/30/2021 JUNIOR HIGH SCHOOL TEACHER TARLAC,INC.
8000.00 N/A CONTRACTUAL NO
ST.PAUL COLLEGES FOUNDATION PANIQUI,
1/6/2017 11/4/2019 JUNIOR HIGH SCHOOL TEACHER TARLAC,INC.
8000.00 N/A CONTRACTUAL NO

6/6/2016 7/4/2017 JUNIOR HIGH SCHOOL TEACHER ST.PAUL COLLEGES FOUNDATION PANIQUI, 8000.00 N/A CONTRACTUAL NO
TARLAC,INC.

(Continue on separate sheet if necessary)

SIGNATURE DATE April 1, 2024

CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (Write in
full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

N/A

(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 ATTENDANCE Type of LD
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
( Managerial/ CONDUCTED/ SPONSORED BY
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
From To Technical/etc)

SAFE SPACES ACT - Repubic Act No. 11313 01/29/2024 01/29/2024 8 Technical DEPED SCHOOL INSET TRAINING
Child Rigths Policy : Adopting the rights based
education frames in the Phil. Basic educ. (Deped 01/27/2024 01/27/2024 8 Technical DEPED SCHOOL INSET TRAINING
Order 31.s.2022)
Policy Guidelines on the implemetation of the
comprehensive sexuality eduaction (Deped Order no. 01/26/2024 01/26/2024 8 Technical DEPED SCHOOL INSET TRAINING
31 s. 2018)
Child Protection Policy(DepEd Order No. 20, s. 2014) 01/25/2024 01/25/2024 8 Technical DEPED SCHOOL INSET TRAINING
Training Course of the dev't of localized
supplementary learning materials(SLMs) for the tool 01/24/2024 01/24/2024 8 Technical DEPED SCHOOL INSET TRAINING
subjectss(Eng&Fil&Math)
IN-SERVICE TRAINING (INSET) FOR JUNIOR HIGH 09/08/2022 09/10/2022 24 Technical PRIVATE EDUCATION ASSISTANCE
SCHOOL TEACHERS COMMITTEE
IN-SERVICE TRAINING (INSET) FOR SENIOR HIGH 09/29/2022 09/01/2022 24 Technical PRIVATE EDUCATION ASSISTANCE
SCHOOL TEACHERS COMMITTEE
IN-SERVICE TRAINING (INSET) FOR JUNIOR HIGH 3/3/2022 5/3/2022 24.0 Technical PRIVATE EDUCATION ASSISTANCE
SCHOOL TEACHERS COMMITTEE
IN-SERVICE TRAINING (INSET) FOR SENIOR HIGH 02/14/2022 02/16/2022 24.0 Technical PRIVATE EDUCATION ASSISTANCE
SCHOOL TEACHERS COMMITTEE
EVENT MANAGEMENT SERVICES NC III 7/9/2018 09/17/2018 120.0 Technical
TESDA

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

INNOVATIVE N/A N/A

LEADERSHIP

MULTITASKING

INTER PERSONAL SKILLS

COMPUTER LITERATE

(Continue on separate sheet if necessary)

SIGNATURE DATE April 1, 2024

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:
________________________________

35. a. Have you ever been found guilty of any administrative offense?
YES ✘ NO
If YES, give details:
________________________________
________________________________

b. Have you been criminally charged before any court? YES ✘ NO

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? YES ✘ NO
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 ✘ YES NO
phased out (abolition) in the public or private sector? If YES, give details:
________________________________
Finished Contract
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year
(except Barangay election)? YES ✘ NO
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
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?
YES ✘ NO
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?
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? YES ✘ NO
If YES, please specify ID No:

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

ADDRESS TEL. NO.

ID picture taken within
the last 6 months
HECTOR G. FLORES Cuyapo Nueva Ecija 0917-110-3638 3.5 cm. X 4.5 cm
(passport size)
ANGELO D. GARCIA Cuyapo Nueva Ecija 0977-354-8640 With full and handwritten
name tag and signature over
printed name
NOEMI C. BURGOS Cuyapo Nueva Ecija 0945-388-9542
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
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable
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: PRC License

ID/License/Passport No.: 1544330 Signature (Sign inside the box)

Date/Place of Issuance: ROSALES PANGASINAN

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