CS Form No.

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 c
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 fi

I. PERSONAL INFORMATION
2. SURNAME Caballeda
NAME EXTENSION (JR., S
FIRST NAME Junrey

MIDDLE NAME Espelita

3. DATE OF BIRTH
(mm/dd/yyyy) 6/16/1997 16. CITIZENSHIP
✘ Filipino Dual Citizenship

by birth by
4. PLACE OF BIRTH ESCALANYE CITY If holder of dual citizenship, Pls. indicate co
please indicate the details.
5. SEX ✘ Male Female

17. RESIDENTIAL ADDRESS Prk. Nab

6 CIVIL STATUS ✘ Single Married
House/Block/Lot No. Str
Widowed Separated
BALINT
Other/s:
Subdivision/Village Bara
6125 ESCALANTE NEGROS O
7. HEIGHT (m) 5'5
City/Municipality Prov
8. WEIGHT (kg) 70 ZIP CODE
18. PERMANENT ADDRESS Prk. Nab
9. BLOOD TYPE A+
House/Block/Lot No. Str
BALINT
10. GSIS ID NO.
6124 Subdivision/Village Bara
ESCALANTE NEGROS OC
11. PAG-IBIG ID NO. 121229853506
City/Municipality Prov
12. PHILHEALTH NO. 11-2519552115-1 ZIP CODE

13. SSS NO. 06-4155283-6 19. TELEPHONE NO.

14. TIN NO. 726341299000 20. MOBILE NO. 09500707183

15. AGENCY EMPLOYEE NO.
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME
FIRST NAME
2019-421 21. E-MAIL ADDRESS (if any) caballedajunrey@gmail.com
23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME Caballeda

FIRST NAME Eduardo

MIDDLE NAME Espelita

25. MOTHER'S MAIDEN NAME

SURNAME Espelita

FIRST NAME Aurelia

 MIDDLE NAME Regodos (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE LEVEL/
26. PERIOD OF ATTENDANCE UNITS
LEVEL (Write in full) EARNED
(Write in full) (if not
From To
graduated)
ESCALANTE CENTRAL
ELEMENTARY ELEMENTARY SCHOOL
VOCATIONAL / ESCALANTE NATIONAL HIGH
SECONDARY SCHOOL

BACHELOR IN ELEMENTARY
COLLEGE TRADE MONT CARMEL COLLEGE EDUCATION
COURSE
MASTER OF ARTS IN EDUCATIONAL
GRADUATE STUDIES NONESCOST
MANAGEMENT 12
(Continue on separate sheet if necessary)

SIGNATURE DATE Septembe

CS FORM 212 (
AL DATA SHEET
he Work Experience Sheet shall cause the filing of administrative/criminal case/s against the

HEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Dual Citizenship

by birth by naturalization
Pls. indicate country:

Prk. Nabantuan
Street
BALINTAWAK
Barangay
NEGROS OCCIDENTAL
Province

Prk. Nabantuan
Street
BALINTAWAK
Barangay
NEGROS OCCIDENTAL
Province

09500707183

caballedajunrey@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

 (Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2008-2009

2012-2013

2017-2018

e on separate sheet if necessary)

September 19, 2019

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

NAPOLCOM 4/1/2019 WEST VISAYAS STATE UNIVERSITY

DRIVER'S LICENSE LTO SAN CARLOS F10-000694

(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/
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY PAY GRADE (if STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To
ALTERNATIVE LEARNING SCHOOL,
6/4/2019 PRESENT TEACHER 8000.00 CONTRUCTUAL
INC.
1/8/2018 6/4/2018 AREA SUPERVISOR SHELL EASY GAS, CEBU CITY 25000.00 CONTRUCTUAL

CUSTOMERS SERVICE
7/9/2018 4/8/2019
REPRESENTATIVE
TECH MAHINDRA, CITY CEBU 2500.00 CONTRUCTUAL
 (Continue on separate sheet if necessary)

SIGNATURE DATE 09/24/2019

CS FORM 212 (Revised 201
 LICENSE (if applicable)

Date of
Validity

6/16/2021

on separate sheet if necessary)

ption of duties should be indicated in the attached Work Experience sheet. GOV'T
SERVICE

(Y/
N)
on separate sheet if necessary)

CS FORM 212 (Revised 2017), Page 2 of 4

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZ
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (Write in
full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WOR
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/Manag
INCLUSIVE DATES OF
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(Write in full) (mm/dd/yyyy)
From To Technical/etc)

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBER
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGAN
31. SPECIAL SKILLS and HOBBIES 33.
(Write in full)
in fu
 (Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revis
T IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

(Continue on separate sheet if necessary)

D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
only the relevant L&D/training taken for the last five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

(Continue on separate sheet if necessary)

MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(Write
in full)
(Continue on separate 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 theof bureau or office or to the person who has immediate supervision over you in the
chief
Office,
Bureau or Department where you will be apppointed,
a. within the third degree? YES ✘ NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘ NO
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
YES ✘ NO
regulation 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 If YES, give details:
phased 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
YES ✘ NO
(except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
the last 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
a.
items:
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
PRK. BAGONG SILANG, the last 6 mo
VERMONT KHAN JUVAHIB ESCALANTE CITY
9159790680 3.5 cm. X 4.5
(passport si

With full and han

name tag and signa
printed nam

Computer gene
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct or photocopied p
is not accepta
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 PHOTO
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:
 ID/License/Passport No.: F10-000694
Signature (Sign inside the box)

Date/Place of Issuance:
Date Accomplished Right Thumbm

SUBSCRIBED AND SWORN to before me this 24TH , affiant exhibiting his/her validly issued government ID as indicated above.

Person Administering Oath

CS FORM 212 (R
 If YES, give details:
________________________________

If YES, give details:

________________________________
________________________________

If YES, give details:

________________________________
________________________________

✘ NO
If YES, give details:
________________________________
________________________________
✘ NO
If YES, give details:
________________________________
________________________________
✘ NO

✘ NO

✘ NO
If YES, give details (country):

✘ NO

✘ NO

✘ NO

ID picture taken within

the last 6 months
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten

name tag and signature over
printed name

Computer generated
or photocopied picture
is not acceptable

PHOTO
 Right Thumbmark

TH , affiant exhibiting his/her validly issued government ID as indicated above.

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