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 aga
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 CUSIPAG
NAME EXTENSION (JR., SR)
FIRST NAME NELSON

MIDDLE NAME BALAQUI

3. DATE OF BIRTH
(mm/dd/yyyy) 11/26/1986 16. CITIZENSHIP ✘ Filipino Dual Citizenship
✘ by birth by

4. PLACE OF BIRTH SOLANA CAGAYAN If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX ✘ Male Female

Single ✘ Married 17. RESIDENTIAL ADDRESS #50 MACAB

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. S
Other/s: LINA
Subdivision/Village Bar
TUGUEGARAO CITY CAG
7. HEIGHT (m) 1.63
City/Municipality Pro
8. WEIGHT (kg) 70 ZIP CODE 3500

18. PERMANENT ADDRESS #50 MACAB

9. BLOOD TYPE O
House/Block/Lot No. S
LINA
10. GSIS ID NO. 2004240424
Subdivision/Village Bar
TUGUEGARAO CITY
11. PAG-IBIG ID NO. 1210-6621-0484
City/Municipality Pro

12. PHILHEALTH NO. 6-025018809-1 ZIP CODE 3500

13. SSS NO. 1-0947051-5 19. TELEPHONE NO. N/A

14. TIN NO. 272-339-848 20. MOBILE NO. 09066230489

15. AGENCY EMPLOYEE NO.
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME
FIRST NAME
09-0080 21. E-MAIL ADDRESS (if any) bacudmariaelanie@yahoo.com
CUSIPAG 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) JONELYN A. CUSIPAG
JOCELYN

MIDDLE NAME ANGCO JONELOU A. CUSIPAG

OCCUPATION HOUSEKEEPER JONEL A. CUSIPAG

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME CUSIPAG

NAME EXTENSION (JR., SR)
FIRST NAME DULO CATALINO
 MIDDLE NAME MACABABBAD

25. MOTHER'S MAIDEN NAME

SURNAME BULAQUI

FIRST NAME TERESITA

MIDDLE NAME MORA (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

ELEMENTARY LINAO ELEMENTARY SCHOOL ELEMENTARY GRADUATE 1979

SECONDARY
VOCATIONAL /
CAGAYAN NATIONAL HIGH SCHOOL HIGH SCHOOL GRADUATE 1985

TRADE TECHNICAL CURRICULUM -

CAGAYAN STATE UNIVERSITY 1989
ELEMENTARY TECHNOLOGY
TRADE
COURSE BS INDUSTRIAL TECHNOLOGY
COLLEGE CAGAYAN STATE UNIVERSITY
MAJOR IN ELECTRICAL

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM
 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)

Dual Citizenship

by naturalization

Pls. indicate country:

MACABABBAD ST.
Street
LINAO EAST
Barangay
CAGAYAN
Province
3500

MACABABBAD ST.
Street
LINAO EAST
Barangay
CAGAYAN
Province

N/A

09066230489

bacudmariaelanie@yahoo.com

DATE OF BIRTH (mm/dd/yyyy)

5/2/1996

8/23/1997

11/16/2002
 (Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

parate sheet if necessary)

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

(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 GOV'T SERVICE
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 (Y/ N)

(Continue on separate sheet if necessary)

SIGNATURE DATE
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 POSI
From To

(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/ COND
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/
Technical/etc)
From To
 (Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

COMPUTER LITERATE N/A

DATA ENCODING

PAPER WORKS/CLERICAL WORKS

(Continue on separate sheet if necessary)

SIGNATURE DATE
PLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

ate sheet if necessary)

AMS ATTENDED
years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)
ate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION

(Write in full)

N/A

ate sheet if necessary)

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: N/A

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

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
BRGY. CAPT. CLIFFORD MACABABBAD LINAO EAST TUG. CITY 3.5 cm. X 4.5 cm
(passport size)

PROFESSOR BENJAMIN ARAO UGAC SUR TUG. CITY With full and handwritten
name tag and signature over
printed name
PROBO LASAM-DEAN OF COLLEGE OF TECHNOLOGY UGAC NORTE TUG. CITY
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: DRIVER'S LICENSE

ID/License/Passport No.: B04-96-034-134

Signature (Sign inside the box)

Date/Place of Issuance: 10/03/2016 TUGUEGARAO 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