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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 EDOSMA
NAME EXTENSION (JR., SR
FIRST NAME DORIS

MIDDLE NAME CABOLBOL


3. DATE OF BIRTH
(mm/dd/yyyy) 01/09/1973 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by birth b
4. PLACE OF BIRTH BIGA, LUGA-IT, MISAMIS ORIENTAL If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male ✘ Female

✘ Single Married 17. RESIDENTIAL ADDRESS PUROK ROSAL B,


6 CIVIL STATUS
House/Block/Lot No. S
Widowed Separated
VILLA
Other/s:
Subdivision/Village Ba
ILIGAN CITY LANAO
7. HEIGHT (m) 152.4CM
City/Municipality Pr
8. WEIGHT (kg) 50 ZIP CODE

18. PERMANENT ADDRESS PUROK ROSAL B,


9. BLOOD TYPE "A"
House/Block/Lot No. S
N/A VILLA
10. GSIS ID NO. 2000171204
Subdivision/Village Ba
ILIGAN CITY LANAO
11. PAG-IBIG ID NO. 195000021301
City/Municipality Pr

12. PHILHEALTH NO. 150000740421 ZIP CODE 9200

13. SSS NO. 08-1169218-6 19. TELEPHONE NO. N/A

14. TIN NO. 901-698-639 20. MOBILE NO. 0948-7453-633

15. AGENCY EMPLOYEE NO. 2007-025 21. E-MAIL ADDRESS (if any) doris.edosma@g.msuiit.edu.
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) N/A CHRISTIAN RYAN EDOSMA
FIRST NAME N/A

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME EDOSMA


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

MIDDLE NAME PAICAN

25. MOTHER'S MAIDEN NAME

SURNAME CABOLBOL

FIRST NAME LORENZA

MIDDLE NAME MANSOLINAY (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

VILLA VERDE ELEMENTARY SCHOOL, VILLA


ELEMENTARY
VERDE, ILIGAN CITY
PRIMARY EDUCATION 1980 1986 GRADUATED
MINDANAO STATE UNIVERSITY-ILIGAN INSTITUTE OF
SECONDARY
VOCATIONAL / TECHNOLGOY, DEVELOPMENTAL HIGH SCHOOL, ILIGAN HIGH SCHOOL 1986 1990 GRADUATED
CITY

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

TRADE
MINDANAO STATE UNIVERSITY-ILIGAN INSTITUTE OF BACHELOR OF SCIENCE IN OFFICE
COURSE
COLLEGE TECHNOLGOY, ILIGAN CITY MANAGEMENT
1990 1995 GRADUATED

MINDANAO STATE UNIVERSITY- MARAWI


GRADUATE STUDIES
CITY
MA IN PUBLIC ADMINISTRATION 2009 2011 18 UNITS
(Continue on separate sheet if necessary)

SIGNATURE DATE MAY

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)

NAME EXTENSION (JR., SR) N/A

Dual Citizenship

by naturalization
Pls. indicate country:

N/A
Street
VILLA VERDE
Barangay
LANAO DEL NORTE
Province

N/A
Street
VILLA VERDE
Barangay
LANAO DEL NORTE
Province

N/A

0948-7453-633

doris.edosma@g.msuiit.edu.ph

DATE OF BIRTH (mm/dd/yyyy)

08/23/2007

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

3RD
1986
HONOR
1990 N/A

N/A N/A

1995 N/A

N/A N/A
parate sheet if necessary)

MAY 5,2017

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

DATA ENCODER LEVEL I FEB. 5, 2007 TESDA, MARIA CRISTINA, ILIGAN CITY 2610124

(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

DATA ENTRY MACHINE OPERATOR II MINDANAO STATE UNIVERSITY-ILIGAN INSTITUTE OF


6/1/2010 PRESENT TECHNOLOGY, CASHIERING DIVISION
16,121.00 08-3 PERMANENT
(DEMO II)
MINDANAO STATE UNIVERSITY-ILIGAN INSTITUTE OF
10/1/2009 5/31/2010 ADMINISTRATIVE ASSISTANT II TECHNOLOGY, CASHIERING DIVISION
11,636.00 08-1 TEMPORARY
MINDANAO STATE UNIVERSITY-ILIGAN INSTITUTE OF
3/5/2007 9/30/2009 ADMINISTRATIVE AIDE VI TECHNOLOGY, CASHIERING DIVISION
10,132.98 06-1 CASUAL
MASTERS TECHNOLOGICAL INSTITUTE
12/15/1999 3/5/2007 REGISTRAR 4,200.00 N/A CONTRACTUAL
OF MINDANAO
MASTERS TECHNOLOGICAL INSTITUTE
11/10/1997 12/14/1999 CASHIER, LECTURER 3,200.00 N/A CONTRACTUAL
OF MINDANAO
4/2/1997 11/10/1997 OFFICER IN-CHARGE CEBU PACIFIC AIR (BOOKING OFFICE) 1,600.00 N/A CONTRACTUAL
(Continue on separate sheet if necessary)

SIGNATURE DATE MAY 5, 2017

CS FORM 212 (Revised 20


LICENSE (if applicable)

Date of
Validity

09/02/2008

arate sheet if necessary)

GOV'T
SERVICE

(Y/
N)
YES

YES

YES

NO

NO

NO
arate 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

GAGMAY'NG SIMBAHANONG KATILINGBAN (GSK) 10/14/2004 PRESENT 1 MEMBER

(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
NATIONAL ARC
SEMINAR-WORKSHOP ON BASIC RECORDS AND ARCHIVES MANAGEMENT 03/01/2017 03/02/2017 16 SAFETY STATE UNIVE

PROGRAM TO INSTITUTIONALIZE MERITOCRACY AND EXCELLENCE IN HUMAN MINDAN


07/29/2016 07/29/2016 7 QUALITY
RESOURCE MANAGEMENT ACCREDITATION ORIENTATION INS
INTERNATIONAL ORGANIZATION FOR STANDARDIZATION (ISO) 9001:2015 MINDAN
04/12/2016 04/12/2016 8 QUALITY
AWARENESS SEMINAR INS
PLANNING, BUDGETING, EXECUTION AND MONITORING FOR RESULTS-PILLARS PHILIPPINE
11/04/2015 11/07/2015 24 TECHNICAL
OF A STRONG PUBLIC FINANCIAL MANAGEMENT BUDG
MINDAN
TWO-DAY CLUSTER PLANNING 12/12/2014 12/13/2014 16 TECHNICAL
INS
YEAR-END ASSESSMENT OF WORK AND FINANCIAL PLAN FOR 2014 AND MINDAN
10/30/2014 10/31/2014 16 TECHNICAL
WORKSHOP FOR PREPARATION OF WORK AND FINANCIAL PLAN FOR 2015-2016 INS

ANNUAL TAX CAMPAIGN SEMINAR FOR TAXABLE YEAR 2014 02/24/2014 02/24/2014 8 TECHNICAL BUREAU OF

MINDAN
INCOME GENERATING PROGRAM STRATEGIC PLANNING AND WORKSHOP 09/06/2013 09/09/2013 24 TECHNICAL
INS

SEMINAR WORKSHOP ON STRATEGIC PERFORMANCE MANAGEMENT SYSTEM 06/18/2013 06/19/2013 16 TECHNICAL CIVIL SE

SEMINAR WORKSHOP ON BASIC RECORDS AND ARCHIVES MANAGEMENT 01/22/2013 01/24/2013 24 SAFETY NATIONAL

ORIENTATION SEMINAR ON CHED ENCHANCED GUIDELINES AND PROCEDURES COMMISSIO


03/30/2012 03/30/2012 8 TECHNICAL
GOVERNING INCREASE IN TUITION AND OTHER SCHOOL FEES REGION X
MINDAN
TECHNOLOGY OF PARTICIPATION TRAINING WORKSHOP 05/21/2011 05/22/2011 16 TECHNICAL
INS
TRAINING ON PUBLIC SERVICE EXCELLENCE PROGRAM MODULE MINDAN
12/10/2010 12/11/2010 16 COMMUNICATION
5:CELEBRATING ACCOMPLISHMENTS INS
TRAINING ON PUBLIC SERVICE EXCELLENCE PROGRAM MODULE 4: SERVICE MINDAN
9/21/2010 9/22/2010 16 COMMUNICATION
IMPLEMENTATION PROGRAM INS
TRAINING ON PUBLIC SERVICE EXCELLENCE PROGRAM MODULE 3: SERVICE MINDAN
08/05/2010 08/06/2010 16 COMMUNICATION
AUDIT PROGRAM INS
TRAINING ON PUBLIC SERVICE EXCELLENCE PROGRAM MODULE 1: BASIC MINDAN
05/25/2010 05/26/2010 16 COMMUNICATION
CUSTOMER SERVICE SKILLS INS
MINDAN
FIRST PARTICIPATING STRATEGIC PLANNING WORKSHOP 11/21/2009 11/22/2009 16 TECHNICAL
INS
PHILIPP
BASIC COMPUTER SKILLS FOR RECORDS MANAGEMENT PROFESSIONAL 03/25/2009 03/27/2009 24 TECHNICAL
ASS

SEMINAR WORKSHOP ON MANAGEMENT OF ELECTRONIC RECORDS 12/04/2007 12/06/2007 24 TECHNICAL NATIONAL

COMPETENCY BASED CURRICULUM DEVELOPMENT WORKSHOP CUM TECHNIC


05/25/2006 05/26/2006 16 TECHNICAL
NAMIS/MIS ORIENTATION DE
ORIENTATION OF THE PREPARATION OF THE CERTIFICATION, AUTHENTICATION, COMMISS
03/02/2001 03/02/2001 8 TECHNICAL
VERIFICATION OF STUDENTS RECORD AND SPECIAL ORDER FOR GRADUATION
(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


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

MINDANAO
ENCODING ENCODER-REGIONAL CHAMPION TECHNOLOG
ASSOCIATIO
TYPING ALUMNI F

COMPUTER LITERATE

FILLING

(Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

MEMBER

eparate sheet if necessary)


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

CONDUCTED/ SPONSORED BY
(Write in full)

NATIONAL ARCHIVES OF THE PHILIPPINES AND MINDANAO


STATE UNIVERSITY-ILIGAN INSTITUTE OF TECHNOLOGY

MINDANAO STATE UNIVERSITY-ILIGAN


INSTITUTE OF TECHNOLGOY
MINDANAO STATE UNIVERSITY-ILIGAN
INSTITUTE OF TECHNOLGOY
PHILIPPINE ASSOCIATION FOR GOVERNMENT
BUDGET ADMINISTRATION, INC.
MINDANAO STATE UNIVERSITY-ILIGAN
INSTITUTE OF TECHNOLGOY
MINDANAO STATE UNIVERSITY-ILIGAN
INSTITUTE OF TECHNOLGOY

BUREAU OF INTERNAL REVENUE, ILIGAN CITY

MINDANAO STATE UNIVERSITY-ILIGAN


INSTITUTE OF TECHNOLGOY

CIVIL SERVICE COMMISSION REGION X

NATIONAL ARCHIVES OF THE PHILIPPINES

COMMISSION ON HIGHER EDUCATION


REGION X
MINDANAO STATE UNIVERSITY-ILIGAN
INSTITUTE OF TECHNOLGOY
MINDANAO STATE UNIVERSITY-ILIGAN
INSTITUTE OF TECHNOLGOY
MINDANAO STATE UNIVERSITY-ILIGAN
INSTITUTE OF TECHNOLGOY
MINDANAO STATE UNIVERSITY-ILIGAN
INSTITUTE OF TECHNOLGOY
MINDANAO STATE UNIVERSITY-ILIGAN
INSTITUTE OF TECHNOLGOY
MINDANAO STATE UNIVERSITY-ILIGAN
INSTITUTE OF TECHNOLGOY
PHILIPPINE RECORDS MANAGEMENT
ASSOCIATION INCORPORATED

NATIONAL ARCHIVES OF THE PHILIPPINES

TECHNICAL EDUCATIONAL SKILLS AND


DEVELOPMENT AUTHORITY
COMMISSION ON HIGHER EDUCATION
REGION X
eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)
MINDANAO STATE UNIVERSITY-ILIGAN INSTITUTE OF
TECHNOLOGY, ADMINISTRATIVE AND NON-TEACHING
UNION (MSU-IIT ANTEU)
ASSOCIATION OF ILIGAN INSTITUTE OF TECHNOLOGY
ALUMNI FOUNDATION, INCORPORATED (AIITAFI)

eparate sheet if necessary)

MAY 5, 2017
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 ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘

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? RESIGNATION
________________________________
________________________________
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: NOT MARRIED

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

NAME ADDRESS TEL. NO.


ID picture taken within
ST. LAWRENCE INSTITUTE OF the last 6 months
DR. ALFREDO C. LOPEZ TECHNOLOGY, ILIGAN CITY
(063)223-1874 3.5 cm. X 4.5 cm
(passport size)
MINDANAO STATE UNIVERSITY-ILIGAN INSTITUTE OF
MS. SAHRIMA D. MACKNO TECHNOLOGY, CASHIERING DIVISION (063)223-2352 With full and handwritten
name tag and signature over
printed name
MS. JOY A. ABAN TIBANGA, ILIGAN CITY (063)221-9218
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: AGENCY EMPLOYEE ID

ID/License/Passport No.: 2007-025


Signature (Sign inside the box)
MAY 5, 2017
Date/Place of Issuance: APRIL 4, 2007
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