Page 1806 - AACCUP Accreditation_AreaIV

CS Form No. 212
PERSONAL DATA SHEET
Revised 2017

WARNING: Any misinterpretation 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 LANIA
NAME EXTENSION (JR., SR)
FIRST NAME TOMASA
MIDDLE NAME TANGONAN
3. DATE OF BIRTH JULY 01,1964
(mm/dd/yyyy) 16. CITIZENSHIP Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH SAN MATEO If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female
6 CIVIL STATUS Single Married 17. RESIDENTIAL ADDRESS BLK8 LOT 2
Widowed Separated House/Block/Lot No. Street
EDCO VILLAGE CASTILLO
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 4'11" ECHAGUE ISABELA
City/Municipality Province
8. WEIGHT (kg) 57KG ZIP CODE 3309
9. BLOOD TYPE "O" 18. PERMANENT ADDRESS
House/Block/Lot No. Street
10. GSIS ID NO. 64070102569 SALINUNGAN EAST
Subdivision/Village Barangay
11. PAG-IBIG ID NO. 134000744981 SAN MATEO ISABELA
City/Municipality Province
12. PHILHEALTH NO. 06-00006062-2 ZIP CODE 3318

13. SSS NO. 01-09473949 19. TELEPHONE NO. N/A
14. TIN NO. 166307898 20. MOBILE NO. 09974828219/ 09151320185

15. AGENCY EMPLOYEE NO. TTL070164 21. E-MAIL ADDRESS (if any) babylania3@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME LANIA ( DECEASED) 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
GREG VAN RUSSEL
FIRST NAME GREGORIO NAME EXTENSION (JR., SR) 25/07/1987
MIDDLE NAME MELOCOTONES GERBIE ANNA 31/07/1989
OCCUPATION N/A MAE RUTH 06/05/1991
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME TANGONAN ( DECEASED)
FIRST NAME BERNARDO SR
MIDDLE NAME ANDAYA
25. MOTHER'S MAIDEN NAME SEGUNDO (DECEASED)

SURNAME TANGONAN
FIRST NAME PLACIDA
MIDDLE NAME PAGUIBITAN (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
SCHOLARSHIP/
HIGHEST LEVEL/
PERIOD OF ATTENDANCE
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE YEAR ACADEMIC

LEVEL UNITS EARNED
(Write in full) (Write in full) GRADUATED HONORS
(if not graduated)
From To RECEIVED
ELEMENTARY MAPUROC ELEMENTARY SCHOOL GRADE SCHOOL 1971 1976 ELEMENTARY 1976 SALUTATORIA
N