CS Form No. 212
PERSONAL DATA SHEET
Revised 2017
WARNING: Any misrepresentation 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.
(Do not fill up. For CSC use only)
1. CS ID No.
Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE.
I. PERSONAL INFORMATION
DELA CRUZ
2. SURNAME
MARIA
MIDDLE NAME
CHAVEZ
3. DATE OF BIRTH
(mm/dd/yyyy)
12/07/1996
4. PLACE OF BIRTH
Pasay City
16. CITIZENSHIP
Filipino
Dual Citizenship
by birth
Male
Female
6 CIVIL STATUS
Single
Married
Widowed
Separated
please indicate the details.
157.4
8. WEIGHT (kg)
50
N/A
Block 51
House/Block/Lot No.
Sitio Batoato
Subdivision/Village
Valenzuela City
City/Municipality
17. RESIDENTIAL ADDRESS
Other/s:
7. HEIGHT (m)
N/A
Street
192
Barangay
Metro Manila
Province
ZIP CODE
1440
Block 10
House/Block/Lot No.
Villamor Air Base
Subdivision/Village
Pasay City
18. PERMANENT ADDRESS
O
by naturalization
Pls. indicate country:
If holder of dual citizenship,
5. SEX
9. BLOOD TYPE
N/A
NAME EXTENSION (JR., SR)
FIRST NAME
1st
Street
183
Barangay
Metro Manila
10. GSIS ID NO.
N/A
11. PAG-IBIG ID NO.
N/A
12. PHILHEALTH NO.
N/A
ZIP CODE
1309
13. SSS NO.
N/A
19. TELEPHONE NO.
N/A
14. TIN NO.
N/A
20. MOBILE NO.
15. AGENCY EMPLOYEE NO.
N/A
21. E-MAIL ADDRESS (if any)
City/Municipality
Province
0955-0580826
asdf@gmail.com
II. FAMILY BACKGROUND
N/A
22. SPOUSE'S SURNAME
23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
N/A
DATE OF BIRTH (mm/dd/yyyy)
N/A
N/A
N/A
N/A
N/A
OCCUPATION
N/A
N/A
N/A
EMPLOYER/BUSINESS NAME
N/A
N/A
N/A
BUSINESS ADDRESS
N/A
N/A
N/A
TELEPHONE NO.
N/A
N/A
N/A
24. FATHER'S SURNAME
MORALES
N/A
N/A
N/A
N/A
N/A
N/A
FIRST NAME
MIDDLE NAME
N/A
NAME EXTENSION (JR., SR)
PEDRO
FIRST NAME
N/A
MARTINEZ
MIDDLE NAME
N/A
N/A
SURNAME
MORALES
N/A
N/A
FIRST NAME
ROSALIA
N/A
N/A
MIDDLE NAME
TABUNDA
25. MOTHER'S MAIDEN NAME
(Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
26.
LEVEL
NAME OF SCHOOL
(Write in full)
YEAR
GRADUATED
SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED
ELEMENTARY
2002
2008
N/A
2008
N/A
NAME OF SCHOOL
(Write in full, do not abbreviate)
HIGH SCHOOL
2008
2012
N/A
2012
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
NAME OF SCHOOL
(Write in full, do not abbreviate)
(Write in full, do not abbreviate)
2012
2016
N/A
2016
N/A
N/A
N/A
N/A
N/A
N/A
SECONDARY
GRADUATE STUDIES
HIGHEST LEVEL/
UNITS EARNED
(if not graduated)
To
ELEMENTARY
COLLEGE
PERIOD OF ATTENDANCE
From
NAME OF SCHOOL
(Write in full, do not abbreviate)
VOCATIONAL /
TRADE COURSE
BASIC EDUCATION/DEGREE/COURSE
(Write in full)
N/A
COURSE
N/A
(Continue on separate sheet if necessary)
SIGNATURE
Computer generated or photocopied signature is not acceptable
DATE
March 24, 2022
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27.
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER
SPECIAL LAWS/ CES/ CSEE
BARANGAY ELIGIBILITY / DRIVER'S LICENSE
LICENSE (if applicable)
RATING
(If Applicable)
DATE OF
EXAMINATION /
CONFERMENT
PLACE OF EXAMINATION / CONFERMENT
RA 1080 - PSYCHOMETRICIAN LICENSURE EXAM
75.0
01/01/2016
N/A
N/A
N/A
NUMBER
Date of
Validity
MANILA
11111
01/01/2024
N/A
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N/A
N/A
N/A
N/A
GOV'T
SERVICE
(Y/ N)
(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
(mm/dd/yyyy)
POSITION TITLE
(Write in full/Do not abbreviate)
DEPARTMENT / AGENCY / OFFICE / COMPANY
(Write in full/Do not abbreviate)
MONTHLY
SALARY
SALARY/ JOB/ PAY
GRADE (if
applicable)& STEP
(Format "00-0")/
INCREMENT
STATUS OF
APPOINTMENT
HUMAN RESOURCE SUPERVISOR
COLA COLA COMPANY
P35,000.00
N/A
REGULAR
NO
N
From
To
03/24/2022
PRESENT
01/02/2017
03/23/2022
HUMAN RESOURCE STAFF
COLA COLA COMPANY
P25,000.00
N/A
REGULAR
NO
N
07/30/2016
01/01/2017
COMMUNICATIONS EQUIPMENT
OPERATOR
DEPARTMENT OF HEALTH (DOH)
P14,993.00
SG-4
TEMPORARY
YES
Y
N/A
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(Continue on separate sheet if necessary)
SIGNATURE
Computer generated or photocopied signature is not acceptable
DATE
MARCH 24, 2022
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
(Write in full)
29.
INCLUSIVE DATES
(mm/dd/yyyy)
NUMBER OF HOURS
POSITION / NATURE OF WORK
PRESENT
200
VOLUNTEER
N/A
N/A
N/A
N/A
N/A
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N/A
N/A
From
To
COCA COLA FOUNDATION
08/26/2020
N/A
(Continue on separate sheet if necessary)
VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
30.
TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS
(Write in full)
INCLUSIVE DATES OF
ATTENDANCE
(mm/dd/yyyy)
NUMBER OF HOURS
Type of LD
(Managerial/
Supervisory/
Technical/etc)
CONDUCTED/ SPONSORED BY
(Write in full)
From
To
PROBLEM SOLVING SKILLS TRAINING
03/24/2022
03/24/2022
8.0
SUPERVISORY
COLA COLA COMPANY
MICROSOFT EXCEL
01/01/2019
01/03/2019
24.0
TECHNICAL
COLA COLA COMPANY
HR INTERNSHIP/OJT
03/15/2015
06/18/2015
80.0
TECHNICAL
PHILIPPINE AIR FORCE
STRESS MANAGEMENT
03/11/2014
03/11/2014
3.0
FOUNDATION
COLA COLA FOUNDATION
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(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
31.
SPECIAL SKILLS and HOBBIES
32.
NON-ACADEMIC DISTINCTIONS / RECOGNITION
(Write in full)
33.
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in full)
STENOGRAPHY
BEST IN GRAPHIC DESIGN
PSYCHOLOGICAL ASSOCIATION OF THE
PHILIPPINES
JOURNALISTIC WRITING
N/A
N/A
PHOTOGRAPHY
N/A
N/A
VIDEO EDITING
N/A
N/A
GRAPHIC DESIGN
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
(Continue on separate sheet if necessary)
SIGNATURE
Computer generated or photocopied signature is not acceptable
DATE
MARCH 24, 2022
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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
YES
NO
YES
NO
If YES, give details:
N/A
35.
a. Have you ever been found guilty of any administrative offense?
YES
NO
If YES, give details:
N/A
b. Have you been criminally charged before any court?
YES
NO
If YES, give details:
Date Filed:
Status of Case/s:
36.
37.
38.
Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation
by any court or tribunal?
YES
NO
If YES, give details:
________________________________
N/A
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
out (abolition) in the public or private sector?
YES
If YES, give details:
a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)?
YES
NO
N/A
NO
N/A
If YES, give details:
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?
39.
N/A
N/A
YES
NO
If YES, give details:
Have you acquired the status of an immigrant or permanent resident of another country?
YES
N/A
NO
If YES, give details (country):
N/A
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
YES
NO
If YES, please specify:
b.
Are you a person with disability?
c.
Are you a solo parent?
N/A
If YES, please specify ID No:
YES
N/A
NO
N/A
If YES, please specify ID No:
41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)
42.
NAME
ADDRESS
TEL. NO.
JUAN DELA CRUZ
PASAY CITY, METRO MANILA
999999999
JUAN PEDRO
PASAY CITY, METRO MANILA
999999999
JOHN CRUZ
PASAY CITY, METRO MANILA
999999999
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
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.:
123456
Date/Place of Issuance:
03/23/2022 / MANILA
SUBSCRIBED AND SWORN to before me this
Computer generated
or photocopied signature
is not acceptable
ID picture taken within
the last 6 months
4.5 cm. X 3.5 cm
(passport size)
Computer generated
or photocopied picture
is not acceptable
PASSPORT SIZE WITH FULL AND
HANDWRITTEN NAME TAG AND
SIGNATURE OVER PRINTED
NAME
PHOTO
Computer generated
or photocopied thumbmark
is not acceptable
Signature (Sign inside the box)
March 24, 2022
Date Accomplished
Right Thumbmark
, affiant exhibiting his/her validly issued government ID as indicated above.
Person Administering Oath
CS FORM 212 (Revised 2017), Page 4 of 4