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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 ag
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 MONSALE
NAME EXTENSION (JR., SR
FIRST NAME MARK ANTHONY

MIDDLE NAME RAZO


3. DATE OF BIRTH
(mm/dd/yyyy) MAY 08,1997 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH PALIMBANG SULTAN KUDARAT If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX ✘ Male Female

✘ Single Married 17. RESIDENTIAL ADDRESS PUROK


6 CIVIL STATUS
Widowed Separated House/Block/Lot No. S
TAWA
Other/s:
Subdivision/Village Ba
PAGADIAN CITY ZAMBOAN
7. HEIGHT (m) 5'5"
City/Municipality Pr
8. WEIGHT (kg) 55KLS. ZIP CODE 7016

18. PERMANENT ADDRESS PUROK


9. BLOOD TYPE O
House/Block/Lot No. S
TAWA
10. GSIS ID NO.
Subdivision/Village Ba

11. PAG-IBIG ID NO.


PAGADIAN CITY
City/Municipality Pr

12. PHILHEALTH NO. ZIP CODE 7016

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 20. MOBILE NO. 09101765108

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) monsalemark@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME MONSALE


NAME EXTENSION (JR., SR)
FIRST NAME ISIDRO

MIDDLE NAME VECINO

25. MOTHER'S MAIDEN NAME RAZO

SURNAME MONSALE

FIRST NAME IMELDA

MIDDLE NAME RAFALLO (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 TAWAGAN SUR ELEMENTARY SCHOOL

SECONDARY ZAMBOANGA DEL SUR NATIONAL HIGH SCHOOL


VOCATIONAL /

TRADE
COURSE
COLLEGE SOUTHERN MINDANAO COLLEGES

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE OCTOB

CS FORM
L 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:

PUROK SANTAN
Street
TAWAGAN SUR
Barangay
ZAMBOANGA DEL SUR
Province
7016

PUROK SANTAN
Street
TAWAGAN SUR
Barangay
ZAMBOANGA DEL SUR
Province

09101765108

monsalemark@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2008

2012
2018

parate sheet if necessary)

OCTOBER 14,2019

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

REGISTERED ELECTRICAL ENGINEERING


0.8 APRIL 15-16, 2019 SOUTHWESTERN UNIVERSITY,PHINMA
BOARD EXAM
REGISTERED MASTER ELECTRICIAN BOARD
0.8 APRIL 17, 2019 SOUTHWESTERN UNIVERSITY,PHINMA
EXAM

(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
(Continue on separate sheet if necessary)

SIGNATURE DATE OCTOBER 14,2019

CS FORM 212
LICENSE (if applicable)

NUMBER Date of
Validity

0073440 8/5/2022

0060928 8/5/2022

ed Work Experience sheet. GOV'T


SERVICE

STATUS OF
APPOINTMENT

(Y/
N)
OCTOBER 14,2019

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 /
From To

ZAMBOANGA DEL SUR ELECTRIC COOPERATIVE-1 04/17/2017 06/20/2017 320.0 ON-THE-JOB TRAINEE

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

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


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

PROFICIENT IN AUTO-CAD,SKETCHUP,MS INSTITUTE


WORDS, MS POWERPOINT ENGIN
WATCHING DOCUMENTARIES

FISHING

GARDENING

(Continue on separate sheet if necessary)

SIGNATURE DATE
RGANIZATION/S

POSITION / NATURE OF WORK

ON-THE-JOB TRAINEE

tive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)
INSTITUTE OF INTEGRATED ELECTRICAL
ENGINEERS OF THE PHILIPPINES
OCTOBER 14,2019
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
ALVINDA T. PADILLA SAN JOSE, PAGADIAN CITY 9108610332 3.5 cm. X 4.5 cm
(passport size)

JEMMELYN M. NABI TAWAGAN SUR PAGADIAN CITY 9104755800 With full and handwritten
name tag and signature over
printed name
JUVET ARTHUR F. TADIAMON TIGUMA, PAGADIAN CITY 9457762331
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 (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.: 0073440


Signature (Sign inside the box)

Date/Place of Issuance:
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 o


give details (country):

validly issued government ID as indicated above.

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

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