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 MANUEL
N/A
FIRST NAME CRISDIE

MIDDLE NAME BESARRA

3. DATE OF BIRTH
MARCH 10 1989 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by by
✘
birth naturalization
4. PLACE OF BIRTH SAN JOSE CITY NUEVA ECIJA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS ZONE 4

Widowed Separate House/Block/Lot No. Street

PALESTINA
Other/s: d Subdivision/Village Barangay
SAN JOSE CITY NUEVA ECIJA
7. HEIGHT (m) 1.67
City/Municipality Province
8. WEIGHT (kg) 62 ZIP CODE 3121
18. PERMANENT ADDRESS ZONE 4
9. BLOOD TYPE o+
House/Block/Lot No. Street
PALESTINA
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1211-2014-4558 SAN JOSE CITY NUEVA ECIJA

City/Municipality Province
12. PHILHEALTH NO. 01-026520680-9 ZIP CODE 3121

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

14. TIN NO. 706-876-872 20. MOBILE NO. 09268193585

15. AGENCY EMPLOYEE NO. 312585 21. E-MAIL ADDRESS (if any) katerfabros@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME MANUEL 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME MARIBEL

N/A ALEERA NICOLE L. MANUEL NOVEMBER 24 2008

MIDDLE NAME LAZAGA QWYNN MARISHKA L. MANUEL OCTOBER 17 2014

OCCUPATION MIDWIFE

EMPLOYER/BUSINESS NAME LOCAL GOVERNMENT UNIT

BUSINESS ADDRESS N/A

TELEPHONE NO. 9284246832

24. FATHER'S SURNAME MANUEL

N/A
FIRST NAME EDDIE

MIDDLE NAME JUANANI

25. MOTHER'S MAIDEN NAME

SURNAME BESARRA

FIRST NAME CRISTETA

MIDDLE NAME GRAGASIN (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
UNITS ACADEMIC
LEVEL (Write in full) EARNED
GRADUATED
HONORS
(Write in full) (if not RECEIVED
From To
graduated)
ELEMENTARY PALESTINA ELEMENTARY SCHOOL N/A 1996 2002 GRADUATE 2002 N/A
VOCATIONAL / CONSTANCIO PADILLA NATIONAL
SECONDARY
HIGH SCHOOL N/A 2002 2007 GRADUATE 2007 N/A

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

BACHELOR OF SCIENCE IN HOTEL AND
COLLEGE TRADE ARAULLO UNIVERSITY 2009 2013 GRADUATE 2013 N/A
COURSE RESTAURANT MANAGEMENT

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 27 2020

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

NAPOLCOM ENTRANCE EXAM 72.2 OCTOBER 16 2016 BAGUIO CITY N/A 12/17/2016

(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. GOV'T
SERVICE
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 (Y/
N)
PHILIPPINE NATIONAL POLICE- PHP TEMPORAR
11/08/2018/ TO DATE PATROLMAN 29,668 SG 10 YES
POLICE REGIONAL OFFICE 3 Y

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 27 2020

CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (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
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) From To Technical/etc)

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

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

PLAYING BASKETBALL N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 27 2020

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
regulation by any court or tribunal?
YES ✘ NO
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 within
the last 6 months
PINS DOUGLAS V. DULAY BITAS CABATUAN CITY 9155961244 3.5 cm. X 4.5 cm
(passport size)

PCPL GIOVANNI N. MACAYANAN PALESTINA SAN JOSE CITY 9174439305 With full and handwritten
name tag and signature over
printed name
RUFINO ESTABILLO PALESTINA SAN JOSE CITY 9126335839
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct or photocopied picture
is not acceptable
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: PNP ID

ID/License/Passport No.: 09I0200109

Signature (Sign inside the box)
JANUARY 27 2020
Date/Place of Issuance: 09/02/2019
Date Accomplished Right Thumbmark

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

PMAJ. GEMMA C LOMBOY

Person Administering Oath

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