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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 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 PARAS
NAME EXTENSION (JR., SR) N/A
FIRST NAME EMILY
MIDDLE NAME DIZON
3. DATE OF BIRTH
(mm/dd/yyyy) 7/18/1962 16. CITIZENSHIP
✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH San Fernando, Pampanga If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

Single ✘ Married 17. RESIDENTIAL ADDRESS LOT 8 BLOCK 9 DAISY STREET

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
ST. BERNADETTE HEIGHTS DEL ROSARIO
Other/s:
Subdivision/Village Barangay
CITY OF SAN FERNANDO PAMPANGA
7. HEIGHT (m) 149.86
City/Municipality Province
8. WEIGHT (kg) 55 kg. ZIP CODE 2000

18. PERMANENT ADDRESS LOT 8 BLOCK 9 DAISY STREET

9. BLOOD TYPE O
House/Block/Lot No. Street
ST. BERNADETTE HEIGHTS DEL ROSARIO
10. GSIS ID NO. 2001937924
Subdivision/Village Barangay
CITY OF SAN FERNANDO PAMPANGA
11. PAG-IBIG ID NO. 140000532247
City/Municipality Province
12. PHILHEALTH NO. 07-00005586-5 ZIP CODE 2000

13. SSS NO. 0230399345 19. TELEPHONE NO. 045-961-43-77

14. TIN NO. 116-712-091 20. MOBILE NO. 09161617704

15. AGENCY EMPLOYEE NO. 1983-0028 21. E-MAIL ADDRESS (if any) milletparas@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME PARAS 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

NAME EXTENSION (JR., SR)

FIRST NAME JOSE RONNIE PARAS, JOSEPH EMIL DIZON 9/19/1993

MIDDLE NAME BITUIN PARAS, JOHANAYA DIZON 1/3/1993

OCCUPATION TEACHER PARAS, JOSEPH YOHAN DIZON 8/16/2000

EMPLOYER/BUSINESS NAME PAMPANGA HIGH SCHOOL

BUSINESS ADDRESS CITY OF SAN FERNANDO, PAMPANGA
TELEPHONE NO. 045-961-2239
24. FATHER'S SURNAME DIZON
NAME EXTENSION (JR., SR)
FIRST NAME HONORIO
MIDDLE NAME SANTOS
25. MOTHER'S MAIDEN NAME

SURNAME MAGTOTO
FIRST NAME AURORA
MIDDLE NAME LORENZO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ASSUMPTION COLLEGE SAN 1967 1968

ELEMENTARY
FERNANDO ELEMENTARY SCHOOL
ELEMENTARY
1969 1975
N/A 1975 N/A

VOCATIONAL JOSE ABAD SANTOS HIGH SCHOOL 1675 1977

SECONDARY / HIGH SCHOOL N/A 1979 N/A
UNIVERSITY OF THE ASSUMPTION 1977 1979
CENTRAL LUZON TECHNICAL INSTITUTE MEGA TYPING BASIC 1982
COMPUTER TECH & SPECIALIST COMPUTER OPERATION 1995
N/A N/A
TRADE UNIVERSITY OF THE ASSUMPTION CONCORDIA BACHELOR OF SCIENCE IN COMMERCE 1979 1983 1983
COLLEGE
COURSE COLLEGE BACHELOR OF SCIENCE IN NURSING 2006 2009
N/A N/A
2009
GRADUATE STUDIES N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE 05/09/2017 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

SUB PROFESSIONAL 74.94% 12/6/1981 SAN FERNANDO, PAMPANGA N/A N/A

PROFFESIONAL 73.0 7/7/1985 SAN FERNANDO, PAMPANGA N/A N/A

(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
28. INCLUSIVE DATES SALARY/ JOB/ PAY 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 05/09/2017 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) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

(Continue on separate sheet if necessary)

SIGNATURE DATE 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 ✘ 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
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
JBLMGH, CITY OF SAN FERNANDO, the last 6 months
EVELYN T. GAMBOA PAMPANGA
045-9613363 3.5 cm. X 4.5 cm
(passport size)
JBLMGH, CITY OF SAN FERNANDO,
ANNABELLE P. SAGUM PAMPANGA
045-9613363 With full and handwritten
name tag and signature over
JBLMGH, CITY OF SAN FERNANDO, printed name
MICHELLE P. OCAMPO PAMPANGA
045-9643181
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete or photocopied picture
is not acceptable
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 administrative/criminal case/s PHOTO
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: GSIS

ID/License/Passport No.: 2001937924

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 of 4