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 aga
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 GRAGASIN
NAME EXTENSION (JR., S
FIRST NAME SHIRLEY
MIDDLE NAME AFAGA
3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 1/25/1980 ✘ Filipino Dual Citizenship
✘ by birth by
4. PLACE OF BIRTH CALAMAGUI, ILAGAN CITY If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male ✘ Female

Single Married 17. RESIDENTIAL ADDRESS

6 CIVIL STATUS ✘
House/Block/Lot No. S
Widowed Separated
N/A LINA
Other/s:
Subdivision/Village Ba
7. HEIGHT (m) 1.66 JONES ISA
City/Municipality Pr
8. WEIGHT (kg) 63 ZIP CODE 3313

9. BLOOD TYPE B 18. PERMANENT ADDRESS N/A N

House/Block/Lot No. S

10. GSIS ID NO. 02004294649 N/A LINA

Subdivision/Village Ba

11. PAG-IBIG ID NO. 134000026574 JONES

City/Municipality Pr

12. PHILHEALTH NO. 19-089659591-2 ZIP CODE 3313

13. SSS NO. 33-7119989-6 19. TELEPHONE NO. N/A

14. TIN NO. 207-187-894-0 20. MOBILE NO. 09176558839

15. AGENCY EMPLOYEE NO.
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME
FIRST NAME
5322393 21. E-MAIL ADDRESS (if any) shirleygragasin25@gmail.com
GRAGASIN 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) N/A
MICHAEL MICHAEL PSALM B.GRAGASIN

MIDDLE NAME BACENA DARLENE GRACE A.GRAGASIN

OCCUPATION TEACHING
EMPLOYER/BUSINESS NAME LINAMANAN ELEMENTARY SCHOOL
BUSINESS ADDRESS LINAMANAN, JONES, ISABELA
TELEPHONE NO. N/A
24. FATHER'S SURNAME AFAGA (DECEASED)
NAME EXTENSION (JR., SR) N/A
FIRST NAME ARGELITO
MIDDLE NAME LORENZO
25. MOTHER'S MAIDEN NAME

SURNAME DOMINGO (DECEASED)

FIRST NAME ZENAIDA
MIDDLE NAME TADEO (Continue on separate sheet if necessary

III. EDUCATIONAL BACKGROUND

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

CALINAOAN ELEMENTARY
ELEMENTARY GRADE SCHOOL 1986 1992 GRADUATED
SCHOOL, STO. THOMAS,ISABELA
NORTHERN ISABELA ACADEMY,
SECONDARY HIGH SCHOOL 1992 1996 GRADUATED
STO. THOMAS, ISABELA
 VOCATIONAL /

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

TRADE
ISABELA COLLEGES, CAUAYAN
COURSE COMPUTER SECRETARIAL 1997 1999 GRADUATED
CITY
COLLEGE
PHILIPPINE NORMAL UNIVERSITY- BACHELOR IN SECONDARY EDUCATION-
(BSED) MAJOR IN ENGLISH 2002 2006 GRADUATED
IC, ALICIA, ISABELA
NORTHEASTERN COLLEGE, MASTER OF ARTS IN EDUCATION
GRADUATE STUDIES 2013 2016 GRADUATED
SANTIAGO CITY (MA.Ed)
(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM
L DATA SHEET
rience 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)

NAME EXTENSION (JR., SR) N/A

Dual Citizenship

by naturalization
Pls. indicate country:

Street
LINAMANAN
Barangay
ISABELA
Province
3313
N/A
Street
LINAMANAN
Barangay
ISABELA
Province

N/A

09176558839

shirleygragasin25@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

7/30/2010
9/25/2013

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

1992 N/A

FIRST HON.
1996 MENTION
 N/A N/A

1999 N/A

LEADERSHIP
2006 AWARDEE

2016 DIPLOMA

parate sheet if necessary)

CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable)
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

LICENSURE EXAMINATION FOR

78.4% 7/27/2006 TUGUEGARAO CITY, CAGAYAN
TEACHERS (LET)

(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
(Write in full/Do not (Write in SALARY
applicable)& STEP
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To

1/1/2017 PRESENT GRADE SCHOOL TEACHER -I DEPARTMENT OF EDUCATION P 19,620 11

01/01/2016 12/31/2016 GRADE SCHOOL TEACHER -I DEPARTMENT OF EDUCATION P 19, 077 11

08/24/2015 12/31/2015 GRADE SCHOOL TEACHER -I DEPARTMENT OF EDUCATION P 18, 549 11

06/05/2015 08/23/2015 HIGH SCHOOL TEACHER-III DEPARTMENT OF EDUCATION P 21, 436 13

01/04/2013 06/04/2015 HIGH SCHOOL TEACHER-I DEPARTMENT OF EDUCATION P 18, 549 11

01/03/2012 03/31/2012 HIGH SCHOOL TEACHER-I DEPARTMENT OF EDUCATION P 10, 274 N/A

06/06/2011 12/31/2011 HIGH SCHOOL TEACHER-I DEPARTMENT OF EDUCATION P 15, 065 11

CENTRAL ISABELA CHRISTIAN ACADEMY,
06/11/2008 03/31/2010 CLASSROOM TEACHER ILAGAN CITY
7, 500.00 N/A
UNIVERSITY OF MANILA, INTERNATIONAL
07/02/2007 10/30/2007 ENGLISH TEACHER 8, 000.00 N/A
LANGUAGE SCHOOL
MERRY SUNSHINE MONTESSORI
06/03/2006 04/05/2007 CLASSROOM TEACHER SCHOOL, CAUAYAN CITY
5, 500.00 N/A
 (Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212
 LICENSE (if applicable)

NUMBER Date of
Validity

0938702 10/07/2006

ue on separate sheet if necessary)

n of duties should be indicated in the attached Work Experience sheet. GOV'T

SERVICE

STATUS OF
APPOINTMENT

(Y/
N)
PERMANENT YES

PERMANENT YES

PERMANENT YES

PERMANENT YES

PERMANENT YES

CASUAL YES

SUBSTITUTE YES

REGULAR NO

PROBATIONARY NO

PROBATIONARY NO
ue on separate sheet if necessary)

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

WORDA, CHURCH OF GOD,LINAMANAN, JONES, ISABELA 9/1/2016 PRESENT N/A PRAISE AND WORSHI

BRIGADA ESKWELA, LINAMANAN ELEMENTARY SCHOOL 5/22/2016 5/27/2016 48.0 Volunteer

NATIONAL WORSHIP CAMP, CAVITE PROVINCE 4/23/2016 4/27/2016 40.0 Partcipant

BRIGADA ESKWELA, AGLIPAY HIGH SCHOOL, AGLIPAY,
5/18/2015 5/22/2015 40.0 Volunteer
QUIRINO
DAILY VACATION BIBLE SCHOOL, CHURCH OF
5/6/2014 5/8/2014 24.0 Teacher
GOD,LINAMANAN, JONES,ISABELA

(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

SCHOOL-BASED LEARNING ACTION CELLS (LAC) 12/17/2016 12/18/2016 16.0 TECHNICAL DEPARTME

2016 DIVISION SCHOOLS PRESS CONFERENCE (DSPC) 11/21/2016 11/25/2016 40.0 SUPERVISORY DEPARTME

DISTRICT SEMINAR/WORKSHOP/TRAINING ON CAMPUS JOURNALISM 11/16/2016 11/17/2016 16.0 TECHNICAL DEPARTME

SCHOOL-BASED SEMINAR/WORKSHOP/TRAINING ON CAMPUS
11/06/2016 11/08/2016 24.0 TECHNICAL DEPARTME
JOURNALISM
CLUSTER IN-SERVICE TRAINING (INSET) 10/23/2016 10/27/2016 40.0 SUPERVISORY DEPARTME

DISTRICT SEMINAR/WORKSHOP/TRAINING ON CAMPUS JOURNALISM 11/16/2016 11/17/2016 16.0 TECHNICAL DEPARTME

SCHOOL-BASED SEMINAR/WORKSHOP/TRAINING ON CAMPUS
JOURNALISM
11/06/2016 11/08/2016 24.0 TECHNICAL DEPARTME

CLUSTER IN-SERVICE TRAINING (INSET) 10/23/2016 10/27/2016 40.0 TECHNICAL DEPARTME

2016 DISTRICT BSP O'RAL AND GSP ADVENTURE 10/01/2016 10/03/2016 24.0 SUPERVISORY DEPARTME

DISTRICT FOLLOW-THROUGH TRAINIG OF WRITERS ON LOCAL HISTORY

WRITING IN ARALIN PANLIPUNAN 2
03/22/2016 03/23/2016 16.0 TECHNICAL DEPARTME
DIVISION FOLLOW-THROUGH TRAINIG OF WRITERS ON LOCAL HISTORY
03/15/2016 03/16/2016 16.0 TECHNICAL DEPARTME
WRITING IN ARALIN PANLIPUNAN 2
SCHOOL LEARNING ACTION CELLS 12/09/2015 12/11/2015 24.0 TECHNICAL DEPARTME

2015 DIVISION SCHOOLS PRESS CONFERENCE (DSPC) 11/24/2015 11/26/2015 24.0 SUPERVISORY DEPARTME

NATIONAL TRAINING/SEMINAR/WORKSHOP ON CAMPUS JOURNALISM 07/31/2015 08/02/2015 24.0 TECHNICAL DEPARTME

REGIONAL TRAINING OF GRADE-10 ENGLISH TEACHERS OF THE K TO 12 05/06/2015 05/11/2015 48.0 TECHNICAL DEPARTME

EDUCATION SUMMIT 04/27/2015 04/27/2015 8.0 TECHNICAL DEPARTME

2014 REGIONAL SCHOOLS PRESSCONFERENCE (RSPC) 01/07/2015 01/10/2015 32.0 SUPERVISORY DEPARTME

LINGGO NG MGA KABATAAN 12/25/2014 11/27/2014 24.0 TECHNICAL DEPARTME

2014 DIVISION SCHOOLS PRESS CONFERENCE (DSPC) 11/21/2014 11/22/2014 16.0 TECHNICAL DEPARTME

SCHOOL-BASED IN-SERVICE TRAINING ON TEACHERS' DEVELOPMENT 11/20/2014 11/24/2014 40.0 TECHNICAL DEPARTME

SECOND NATIONAL LEADERSHIP TRAINING 10/17/2014 10/19/2014 24.0 TECHNICAL PHILIPPINE

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERS
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

NATI
COMPUTER LITERATE CHAMPION AS A COACH IN CAMPUS JOURNALISM PRO
ORAL AND WRITTEN COMMUNICATIVELY PHILI
CHAMPION IN NEWS WRTING- TEACHER CATEGORY, NATIONAL TRAINING
COMPETENT ELEME
ISABELA
NEWSPAPERING RESOURCE SPEAKER IN CAMPUS JOURNALISM
JONES
SINGING GUEST SPEAKER DURING GRADUATION

LES DRUM

THE GREA

(Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

PRAISE AND WORSHIP LEADER

Volunteer

Partcipant

Volunteer

Teacher

eparate sheet if necessary)

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

CONDUCTED/ SPONSORED BY
(Write in full)

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

PHILIPPINE CENTER OF EXCELLENCE

eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)
NATIONAL ORGANIZATION OF
PROFESSIONAL TEACHERS
 PHILIPPINE ASSOCIATION FOR
ELEMENTARY PAPER ADVISERS
ISABELA ASSOCIATION FOR PUBLIC
SCHOOL TEACHERS
JONES ASSOCIATION FOR PUBLIC
SCHOOL TEACHERS
LES DRUM AND LYRE CORPS-ADVISER

ICT COORDINATOR
THE GREAT SHEPHERD, PAPER ADVISER
AND COORDINATOR
eparate sheet if necessary)

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
YES ✘ NO
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, ✘ YES NO
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? To apply in the government service
________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except YES ✘ NO
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last YES ✘ NO
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)

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
ZENAIDA D. CRISTOBAL PUNGPONGAN, JONES, ISABELA 9161830204 3.5 cm. X 4.5 cm
(passport size)

FRANCISCA B. ALCALDE ZAMORA, CABARROGUIS, QUIRINO 9178377404 With full and handwritten
name tag and signature over
printed name
CHARITY V. RAMISCAL PROGRESO, AGLIPAY, QUIRINO 9178191732
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
is not acceptable
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 LICENSE
ID/License/Passport No.: 0938702 Signature (Sign inside the box)

Date/Place of Issuance: 10/07/2006/ TUGUEGARAO CIT 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