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
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 fil

I. PERSONAL INFORMATION
2. SURNAME TUZON
NAME EXTENSION (JR., SR)
FIRST NAME ROXETTE MARIE

MIDDLE NAME AGUELO

3. DATE OF BIRTH
(mm/dd/yyyy) 10/21/1996 16. CITIZENSHIP ✘ Filipino Dual Citizenship
✘ by birth

4. PLACE OF BIRTH Lupon, Davao Oriental If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

✘ Single Married 17. RESIDENTIAL ADDRESS Blk. 6 Lot 7 and 8 Phase 2

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
Tiongko Village Brgy. Canoco
Other/s:
Subdivision/Village Barangay
Tagum City Davao del N
7. HEIGHT (m) 1.524 m
City/Municipality Province
8. WEIGHT (kg) 40 kilos ZIP CODE
18. PERMANENT ADDRESS Blk. 6 Lot 7 and 8 Phase 2
9. BLOOD TYPE A
House/Block/Lot No. Street
Tiongko Village Brgy. Canoco
10. GSIS ID NO. N/A
Subdivision/Village Barangay
Tagum City
11. PAG-IBIG ID NO. 202692960002
City/Municipality Province
12. PHILHEALTH NO. 16-252476209-9 ZIP CODE 8100

13. SSS NO. 09-4123635-7 19. TELEPHONE NO. N/A

14. TIN NO. 749-645-592-000 20. MOBILE NO. 09754081313

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) langgingaguelo@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME TUZON 23. NAME of CHILDREN (Write full name and list all)
N/A N/A
FIRST NAME JHAN FRITZ

MIDDLE NAME LIM

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME AGUELO

JR.
FIRST NAME DIONISIO

MIDDLE NAME MARTINEZ

25. MOTHER'S MAIDEN NAME GEMMA GUMBA BAGACAY

SURNAME BAGACAY

FIRST NAME GEMMA

MIDDLE NAME GUMBA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE LEVEL/
26. PERIOD OF ATTENDANCE UNITS
LEVEL (Write in full) EARNED
(Write in full) (if not
From To
graduated)
 Sto Nino College of Science and
ELEMENTARY
Technology Inc.
Elementary 6/1/2004 3/30/2009
VOCATIONAL / Sto Nino College of Science and
SECONDARY
Technology Inc.
Secondary 6/1/2009 3/30/2013

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

Bachelor of Secondary Educatiuon Major in
COLLEGE TRADE University of Mindanao Tagum College 6/1/2013 10/30/2017
COURSE English

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

(Continue on separate sheet if necessary)

SIGNATURE DATE January 24,

CS FORM 212 (R
 rative/criminal case/s against the

(Do not fill up. For CSC use only)

ME EXTENSION (JR., SR)

al Citizenship
by birth by naturalization

Pls. indicate country:

Phase 2
Street
Brgy. Canocotan
Barangay
Davao del Norte
Province

Phase 2
Street
Brgy. Canocotan
Barangay
Davao del Norte
Province
0

1313

o@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

N/A

sheet if necessary)

YEAR SCHOLARSHIP/
GRADUATED ACADEMIC HONORS
RECEIVED
2009 4th Honors

2013 Salutatorian

N/A N/A
Service
2017
Awardee
N/A N/A

January 24, 2020

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

Licensure Examination for Teachers 83.2 3/25/2018 UM Matina Campus 1648891

(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/
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY PAY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To
JUNIOR AND SENIOR HIGH SCHOOL STO NINO COLLEGE OF SCIENCE
6/1/2018 3/30/2019 8500.00 CONTRACTUAL
TEACHER AND TECHNOLOGY INC.
CANOCOTAN NATIONAL HIGH
7/16/2019 TEACHER I 20, 754.00 PERMANENT
SCHOOL

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 24, 2020

CS FORM 212 (Revised 2017), Pa
 LICENSE (if applicable)

Date of
Validity

10/21/2021

on separate sheet if necessary)

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

(Y/
N)

on separate sheet if necessary)

JANUARY 24, 2020
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 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
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) From To Technical/etc)

SLAC for Gender and Development Program 12/12/2019 12/12/2019 4 hrs. Technical Canocotan National High School

Department of Education Division of Tagum

ICT Literacy Training-Workshop 10/28/2019 10/29/2019 16 hrs. Technical

Mid-Year Performance Review and Evaluation 10/21/2019 10/25/2019 40 hrs. Technical Canocotan National High School

Department of Education Division of Tagum

PRIMALS Program for Junior High School 9/2/2019 9/6/2019 40 hrs. Technical
2019 Summer In-Service Training for Junior High School Private Education Assistance Committee
4/22/2019 4/24/2019 24 hrs. Technical
Teachers (PEAC)
Whole Child Education and 21st Century Assessment
Strategies 2/23/2019 2/23/2019 8 Hrs. Technical REX Bookstore, Inc.

2D Digital Animation and Visual Designs NC III Training 12/16/2018 1/19/2019 80 hrs. Technical Computer Reseach Network, Inc./ TESDA
2 Day Division Enchancement Training for School Paper
Adviserts on the New Trends and Techniques in Campus 8/8/2018 8/9/2018 16 hrs. Technical Department of Education Division of Tagum
Journalism
Seminar on Constructing DLL and DLP and Visual Sto Nino College of Science and Technology
6/9/2018 6/9/2018 8 hrs. Technical
Materials using ICT Inc.

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 33.
(Write in full) (Write
in full)
NC II GRPHIC AND VISUAL DESIGNS N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 24, 2020

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 theof bureau or office or to the person who has immediate supervision over you in the
chief
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
YES ✘ NO
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, ✘ YES NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or If YES, give details:
phased out (abolition) in the public or private sector? End of Contract
________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year YES ✘ NO
(except Barangay election)?
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
a.
items:
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
Mrs. Beatriz P. Namuag Senanggote Village, Tagum City 9354195820 3.5 cm. X 4.5 cm
(passport size)

Mr. Jigo G. Avenido Asuncion, Tagum City 9500073398 With full and handwritten
name tag and signature over
printed name
Mrs. Noemi Evelyn Y. Cacayorin Rizal Street, Tagum City 9176099505
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct or photocopied picture
is not acceptable
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 PHOTO
filing of 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.: 1648891

Signature (Sign inside the box)
JANUARY 24, 2020
Date/Place of Issuance: 06/20/2018/Davao City
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