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 NALICA
NAME EXTENSION (JR., SR) N.A
FIRST NAME RAILYN

MIDDLE NAME GUISE

3. DATE OF BIRTH
(mm/dd/yyyy) 03/14/1993 16. CITIZENSHIP
✘

4. PLACE OF BIRTH
ABO ABO ESPANOLA BROOKES If holder of dual citizenship, Pls. indicate country:
POINT PALAWAN
please indicate the details.
5. SEX ✘

✘ 17. RESIDENTIAL ADDRESS N/A BALMONTE ST.

6 CIVIL STATUS
House/Block/Lot No. Street
N/A POBLACION DISTRICT I
Subdivision/Village Barangay
BROOKE'S POINT PALAWAN
7. HEIGHT (m) 1.6m
City/Municipality Province
8. WEIGHT (kg) 49 KG ZIP CODE 5305

18. PERMANENT ADDRESS N/A BALMONTE ST.

9. BLOOD TYPE O+
House/Block/Lot No. Street
N/A POBLACION DISTRICT I
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. N.A BROOKE'S POINT PALAWAN

City/Municipality Province

12. PHILHEALTH NO. N.A ZIP CODE 5305

13. SSS NO. N.A 19. TELEPHONE NO. N/A

14. TIN NO. N/A 20. MOBILE NO. 09066398454

15. AGENCY EMPLOYEE NO. N.A 21. E-MAIL ADDRESS (if any) N/A

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME SIMBANAAO 23. NAME OF CHILDREN (writefull name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) JR
FIRST NAME MOSAAB MOMINAH N. SIMBANAAO 12/05/2014

MIDDLE NAME MACUD HISHAM N. SIMBANAAO 03/16/2025

OCCUPATION ALIVE TEACHER

EMPLOYER/BUSINESS NAME BROOKES POINT ELEMENARY SCHOOL

BUSINESS ADDRESS ABO ABO ESPANOLA BROOKES POINT PALAWAN

TELEPHONE NO. 09997155519 NOTHING FOLLOWS

24. FATHER'S SURNAME NALICA

NAME EXTENSION (JR., SR) SR
FIRST NAME RAFAEL

MIDDLE NAME VIRAY

25. MOTHER'S MAIDEN NAME GUISE

SURNAME MADO

FIRST NAME LETY

MIDDLE NAME PAWI (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
From To

ELEMENTARY BARONG BARONG ELEMENTARY ELEMENTARY 2005 2006 GRADUATED 2006 6

SECONDARY BROOKES POINT NAIONAL HIGH SCHOOL K12 GRADE 12 GRADUATe 2023 202 GRADUATED 2024 WITH
VOCATIONAL / HONOR

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

TRADE
COURSE UNDERGRADUAT
COLLEGE PSU BROOKES POINT 1ST COLLAGE N/A N/A E N/A N/A

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

(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

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

(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)

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

(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

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

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

(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)

COOKING N/A N/A

NOTHING FOLLOWS

(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
KENT VOICES DEVELEZ SIBULAN POBLACION DISTRIC I BROOKES POINT the last 6 months
PALAWAN 09485708663 3.5 cm. X 4.5 cm
(passport size)
GERLIE MATARIA POBLACION DISTRIC I BROOKES POINT
PALAWAN With full and handwritten
name tag and signature over
printed name
NADIA MONTING BORROMEO POB. DIST 2 BROOKES POINT PALAWAN 09174702213
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: VOTERS I.D

ID/License/Passport No.: 53060101AG1986MBA20000

Signature (Sign inside the box)

Date/Place of Issuance: 06/10/2010 BROOKES POINT PALAWAN

Date Accomplished Right Thumbmark

Person Administering Oath

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