Professional Documents
Culture Documents
HAJIE
HAJIE
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 cas
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.
I. PERSONAL INFORMATION
2. SURNAME NACINOPA
Other/s:
Subdivision/Village
CALBAYOG CITY
7. HEIGHT (m) 1.64
City/Municipality
8. WEIGHT (kg) 61 ZIP CODE 6710
15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) N/A
III N/A
FIRST NAME CHERYLINE
OCCUPATION HOUSEWIFE
SURNAME JUSAYAN
SECONDARY
VOCATIONAL / SAN POLICARPO NATIONAL HIGHSCHOOL
TRADE
COURSE
COLLEGE NORTHWEST SAMAR STATE UNIVERSITY
k Experience Sheet shall cause the filing of administrative/criminal case/s against the person
MAHARLIKA HIGHWAY
Street
PUROK-1, BRGY. MATOBATO
Barangay
WESTERN SAMAR
Province
6710
MAHARLIKA HIGHWAY
Street
PUROK-1, BRGY. MATOBATO
Barangay
CALBAYOG CITY
Province
N/A
09267773035
N/A
23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
N/A N/A
(Continue on separate sheet if necessary)
HIGHEST LEVEL/
YEAR SCHOLARSHIP/
UNITS
GRADUA ACADEMIC HONORS
EARNED
TED RECEIVED
(if not graduated)
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
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To
(Continue on separate sheet if necessary)
Date of
Validity
te sheet if necessary)
GOV'T
SERVICE
(Y/ N)
te sheet if necessary)
SIGNATURE DATE
LE / VOLUNTARY ORGANIZATION/S
AMS ATTENDED
ve (5) years for Division Chief/Executive/Managerial positions)
CONDUCTED/ SPONSORED BY
(Write in full)
eparate sheet if necessary)
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in full)
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? ________________________________
________________________________
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:
Computer gener
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete or photocopied p
is not accepta
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 PHOTO
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:
ID/License/Passport No.:
Signature (Sign inside the box)
Date/Place of Issuance:
Date Accomplished Right Thumbma
SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated
NO
NO
If YES, give details (country):
NO
NO
NO
Computer generated
or photocopied picture
is not acceptable
PHOTO
Right Thumbmark