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 ag
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

I. PERSONAL INFORMATION
2. SURNAME Gabitanan
Jr.
FIRST NAME Romeo

MIDDLE NAME Titong

3. DATE OF BIRTH
(mm/dd/yyyy) 03\26\1978 16. CITIZENSHIP ✘ Filipino Dual Citizenship
✘ by birth by
4. PLACE OF BIRTH Binalbagan Negros Occidental If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX ✘ Male Female

✘ Single Married 17. RESIDENTIAL ADDRESS

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. S
Catabla Baybay Z
Other/s:
Subdivision/Village Ba
Talisay City Negros
7. HEIGHT (m) 5'6"
City/Municipality Pr
8. WEIGHT (kg) 72Kg ZIP CODE 6115

18. PERMANENT ADDRESS

9. BLOOD TYPE "O"
House/Block/Lot No. S
Villa Sta. Maria Subdivision Sto.
10. GSIS ID NO. 02004093018
Subdivision/Village Ba
Binalbagan
11. PAG-IBIG ID NO. 1211-2990-5513
City/Municipality Pr

12. PHILHEALTH NO. 11-000125825-7 ZIP CODE 6107

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 915-152-690 20. MOBILE NO. 09289959243

15. AGENCY EMPLOYEE NO.
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME
FIRST NAME
0079 21. E-MAIL ADDRESS (if any) romeogabitananjr2@gmail.c
N/A 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
N/A

MIDDLE NAME N/A

OCCUPATION Teacher

EMPLOYER/BUSINESS NAME Inocencio V. Ferrer Memorial School of Fisheries

BUSINESS ADDRESS Gamboa Subdivision, Bgy. Zone 2

TELEPHONE NO. [034] 712-7172

24. FATHER'S SURNAME Gabitanan

Sr.
FIRST NAME Romeo
 MIDDLE NAME Magnao

25. MOTHER'S MAIDEN NAME

SURNAME Titong

FIRST NAME Milagros

MIDDLE NAME Nasataya (Continue on separate sheet if necessary

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL HIGHEST LEVEL/
26. BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE UNITS
LEVEL (Write in EARNED
(Write in full)
full) (if not graduated)
From To

ELEMENTARY Binalbagan South Elementary School

Binalbagan Catholic College High School

SECONDARY /
VOCATIONAL Department

Binalbagan Catholic College Computer Data Processing

TRADE
COURSE Carlos Hilado Memorial State College-College of Bachelor of Secondary Education Major in
COLLEGE
Fisheries General Science and Fish Processing

GRADUATE STUDIES Negros State College of Agriculture Master of Education Major in General Science 9
(Continue on separate sheet if necessary)

SIGNATURE DATE MARC

CS FORM
L DATA SHEET
erience Sheet shall cause the filing of administrative/criminal case/s against the person

EFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

Jr.

Dual Citizenship

by naturalization

Pls. indicate country:

Street
Zone 3
Barangay
Negros Occidental
Province
6115

Street
Sto. Rosario
Barangay
Negros Occidental
Province

09289959243

romeogabitananjr2@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

 (Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

1989-1990

1993-1994

2002-2003

2006-2007 Dean's List

2006-
parate sheet if necessary)

MARCH 15, 2018

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 ap
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

PHILIPPINE LICENSURE EXAMINATION FOR

75.8 AUGUST 27, 2006 COLEGIO DE SAN AGUSTIN-BACOLOD 0983764
TEACHERS (PLET)

(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.
28. INCLUSIVE DATES SALARY/ JOB/ PAY
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

INOCENCIO V. FERRER MEMORIAL

1/1/2018 TO DATE TEACHER II 265,788.00 PERMANENT
SCHOOL OF FISHERIES
INOCENCIO V. FERRER MEMORIAL
1/1/2017 12/31/17 TEACHER II 256,644.00 PERMANENT
SCHOOL OF FISHERIES
INOCENCIO V. FERRER MEMORIAL
1/9/2016 12/31/16 TEACHER II 247,817.00 PERMANENT
SCHOOL OF FISHERIES
INOCENCIO V. FERRER MEMORIAL
1/1/2016 08/31/16 TEACHER I 231,432.00 PERMANENT
SCHOOL OF FISHERIES
INOCENCIO V. FERRER MEMORIAL
01/25/14 12/31/15 TEACHER I 224,820.00 STEP 2 PERMANENT
SCHOOL OF FISHERIES
INOCENCIO V. FERRER MEMORIAL
1/6/2012 11/24/14 TEACHER I 222,588.00 PERMANENT
SCHOOL OF FISHERIES
INOCENCIO V. FERRER MEMORIAL
01/24/11 05/31/12 TEACHER I 205,188.00 PERMANENT
SCHOOL OF FISHERIES
 (Continue on separate sheet if necessary)

SIGNATURE DATE MARCH 15, 2018

CS FORM 212 (Revised 20

 LICENSE (if applicable)

Date of
Validity

03/26/2021

arate sheet if necessary)

GOV'T
SERVICE

(Y/
N)
YES

YES

YES

YES

YES

YES

YES
arate sheet if necessary)

MARCH 15, 2018

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 /
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
ATTENDANCE Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ( Managerial/ CONDUCTED/
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To

DIVISION TRAINING OF NON-MAJOR TEACHERS IN EDUKASYON SA

9/3/2017 11/3/2017 72 HOURS DIVISIO
PAGPAPAKATAO (ESP)

YOUTH FOR ENVIRONMENT IN SCHOOLS ORGANIZATION YES-O CLUB 02/27/2017 02/27/2017 3 HOURS PRO

BRIEFING & ORIENTATION OF YES-O ADVISER ON THE CONDUCT OF THE 5TH

01/13/2017 3 HOURS D
DIVISION YES-O CAMP
ASSESSMENT AND PLANNING WORKSHOP ON THE IMPLEMENTATION OF
1/7/2016 5 HOURS DIVISIO
MANDATED ENVIRONMENTAL POLICIES AND PROGRAMS

15TH MINULUAN FESTIVAL DEPED STARS ON 45 7/9/2014 5 HOURS E

RE-ECHO TRAINING WORKSHOP ON CHILD PROTECTION 09/25/2014 09/26/2014 48 HOURS CESA

DIVISION SCIENCE RESEARCH CONVENTION 12/7/2013 07/13/2013 48 HOURS D

REGIONAL MASS TRAINING OF GRADE 7 TEACHERS ON THE IMPLEMENTATION

05/14/2012 05/18/2012 120 HOURS LA
OF THE K TO 12 BASIC EDUCATION CURRICULUM
 (Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERS
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)
YOUTH
SINGING MASS DANCER 2012-2018 SCHOO

INTERNET BROWSING VOLLEYBALL COACH (BOYS) DISTRICT MEET LEVEL 2015-2017

INTERNET SURFING SEPAK TAKRAW COACH (BOYS) CITY MEET LEVEL 2014

SEPAK TAKRAW COACH (BOYS) DISTRICT LEVEL 2013

SEPAK TAKRAW COACH (BOYS) AREA MEET LEVEL 2012

 (Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

eparate sheet if necessary)

ROGRAMS ATTENDED
five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

DIVISION OF NEGROS OCCIDENTAL

PROJECT CITIZEN OF TALISAY

DANNIE CLARK M. UGUIL

DIVISION OF NEGROS OCCIDENTAL

ERIC M. SARATAN, M.D.

CESAR D. ADAPON, SR., DR. DEV.

DANNIE CLARK M. UGUIL

LA CONSOLACION COLLEGE
eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)
YOUTH FOR THE ENVIRONMENT IN
SCHOOL ORGANIZATION (YES-O)
ADVISER
eparate sheet if necessary)

MARCH 15, 2018

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:

________________________________

a. Have you ever been found guilty of any administrative offense? YES ✘ NO
35.

If YES, give details:

________________________________
________________________________
YES ✘ NO
b. Have you been criminally charged before any court?
If YES, give details:
________________________________
Date Filed:
________________________________
Status of Case/s:
YES ✘ NO
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:
________________________________
YES ✘ NO
________________________________
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? ________________________________
YES ✘ NO
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? YES If YES, give details:
✘ NO

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? YES If YES, give details:
✘ NO

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 YES ✘ NO
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?
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
DENCY GRACE A. PADILLON CHMSC, TALISAY CITY 712-7172 4.5 cm. X 3.5 cm
(passport size)

JUNE A. DIONISIO TALISAY CITY 712-7172

Computer generated
or photocopied picture
LENY V. ARGUILLON TALISAY CITY 712-7172 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: PRC I.D.

ID/License/Passport No.: 0983764

Signature (Sign inside the box)
MARCH 15, 2018
Date/Place of Issuance: 03/08/2017 CEBU CITY, PHILS.
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 o

If YES, give details (country):
, affiant exhibiting his/her validly issued government ID as indicated above.

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