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 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 ALLAS
NAME EXTENSION (JR., SR)
FIRST NAME TIMOTHY JANSEN

MIDDLE NAME BANGI

3. DATE OF BIRTH
(mm/dd/yyyy) 02/25/94 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH TUGUEGARAO CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS 40 TAURUS

Separat House/Block/Lot No. Street

Widowed DOÑA CONSUELO LEONARDA
Other/s: ed Subdivision/Village Barangay
TUGUEGARAO CITY CAGAYAN
7. HEIGHT (m) 1.77m
City/Municipality Province
8. WEIGHT (kg) 61kg ZIP CODE

18. PERMANENT ADDRESS 40 TAURUS

9. BLOOD TYPE A+
House/Block/Lot No. Street
DOÑA CONSUELO LEONARDA
10. GSIS ID NO.
Subdivision/Village Barangay
TUGUEGARAO CITY CAGAYAN
11. PAG-IBIG ID NO.
City/Municipality Province

12. PHILHEALTH NO. ZIP CODE 3500

13. SSS NO. 19. TELEPHONE NO. N/A

14. TIN NO. 724-370-591-000 20. MOBILE NO. 0935-555-4871

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) tiimmmm@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) N/A
FIRST NAME N/A

MIDDLE NAME

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME ALLAS

NAME EXTENSION (JR., SR)
FIRST NAME FLORIANO JR

MIDDLE NAME ARAGON

25. MOTHER'S MAIDEN NAME

SURNAME BANGI

FIRST NAME CATHERINE

MIDDLE NAME PASTORES (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL HIGHEST LEVEL/
26. PERIOD OF ATTENDANCE YEAR SCHOLARSHIP/
BASIC EDUCATION/DEGREE/COURSE UNITS
LEVEL (Write in EARNED
GRADUATED ACADEMIC HONORS
(Write in full) RECEIVED
full) (if not graduated)
From To

ELEMENTARY APARRI KETE SCHOOL ELEMENTARY EDUCATION 2000 2006 2006

SECONDARY /
VOCATIONAL APARRI KETE SCHOOL SECONDARY EDUCATION 2006 2010 2010

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

TRADE
COURSE
COLLEGE CAGAYAN STATE UNIVERSITY- CARIG BACHELOR OF ARTS IN ENGLISH 2012 2016 2016

GRADUATE STUDIES CAGAYAN STATE UNIVERSITY- ANDREWS BACHELOR OF LAWS 2016 PRESENT

(Continue on separate sheet if necessary)

SIGNATURE DATE 9/25/2019

CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable)
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

CAREER SERVICE (PROFESSIONAL) AUG. 6, 2017 CAUAYAN CITY

(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
(Write in full/Do not (Write in SALARY
applicable)& STEP
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To

1/6/2018 7/13/2019 ADMINISTRATIVE AIDE III Tuguegarao City- LGU 6500.00 1

 (Continue on separate sheet if necessary)

SIGNATURE DATE
CS
 LICENSE (if applicable)

NUMBER Date of
Validity

ue on separate sheet if necessary)

duties should be indicated in the attached Work Experience sheet.

GOV'T SERVICE
STATUS OF
APPOINTMENT
(Y/ N)

Job Order Y
ue on separate sheet if necessary)

9/25/2019
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 / NATURE OF WORK
From To

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

(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/ SPONSORED BY
NUMBER OF HOURS
(Write in full) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To

KATARUNGANG PAMBARANGAY PROGRAM 7/11/2018 6/11/2018 16.0 TUGUEGARAO CITY GOVERNMENT

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

COMMUNICATION AND WRITTEN SKILLS IGLESIA NI CRISTO

COMPUTER LITERATE

AUTOMOTIVE REPAIRING

COMPUTER TROUBLESHOOTING

(Continue on separate sheet if necessary)

SIGNATURE DATE 9/25/2019

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? ________________________________
________________________________
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:

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

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
MS. REYFERSON A. CALAYAN TUGUEGARAO CITY, CAGAYAN 3.5 cm. X 4.5 cm
(passport size)

MR. BERNARDINO E. SABADO TUGUEGARAO CITY, CAGAYAN With full and handwritten
name tag and signature over
printed name

Computer generated
42. or photocopied picture
I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and 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: TIN I.D

ID/License/Passport No.: 724-370-591-000

Signature (Sign inside the box)
9/25/2019
Date/Place of Issuance: 06/22/2018-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), P

e.

2017), Page 4 of 4