CS Form No.
212
PERSONAL DATA SHEET
Revised 2017
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* PATIKAMAN CITEZENSHIP
NAME EXTENSION (JR., SR)
FAIZAL
FIRST NAME* Please indicate country:
MIDDLE NAME* USOP Afghanistan
3. DATE OF BIRTH *
(mm/dd/yyyy) 12-10-1997 16. CITIZENSHIP* Albania
Algeria
4. PLACE OF BIRTH* LABANGAL, GENERAL SANTOS CITY If holder of dual citizenship, Pls. indicate country: Andorra
please indicate the details.
5. SEX* Philippines Angola
17. RESIDENTIAL ADDRESS N/A PRK. BULAONG EXTENSION Antigua and Barbuda
6 CIVIL STATUS*
House/Block/Lot No. Street* Argentina
N/A LABANGAL Armenia
Aruba
Subdivision/Village* Barangay* Australia
GENERAL SANTOS CITY SOUTH COTABATO Austria
7. HEIGHT (m)* N/A
City/Municipality* Province* Azerbaijan
8. WEIGHT (kg)* N/A ZIP CODE* 9500 Bahamas, The
18. PERMANENT ADDRESS N/A PRK. BULAONG EXTENSION Bahrain
9. BLOOD TYPE* N/A
House/Block/Lot No. Street* Bangladesh
N/A LABANGAL Barbados
10. GSIS ID NO. N/A
Subdivision/Village* Barangay* Belarus
GENERAL SANTOS CITY SOUTH COTABATO Belgium
11. PAG-IBIG ID NO. N/A
City/Municipality* Province* Belize
12. PHILHEALTH NO. N/A 9500 Benin
13. SSS NO. N/A 19. TELEPHONE NO. N/A Bhutan
20. MOBILE NO.* (Ex.
14. TIN NO. 706-382-847 09991234567) 09358916594 Bolivia
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) Faizalpatikaman@gmail.com Bosnia and Herzegovin
II. FAMILY BACKGROUND Botswana
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy) Brazil
NAME EXTENSION (JR., SR) Brunei
FIRST NAME N/A N/A
Bulgaria
MIDDLE NAME Burkina Faso
OCCUPATION Burma
EMPLOYER/BUSINESS NAME Burundi
BUSINESS ADDRESS Cambodia
TELEPHONE NO. Cameroon
24. FATHER'S SURNAME* PATIKAMAN Canada
NAME EXTENSION (JR., SR) Cape Verde
MUSA
FIRST NAME* Central African Republ
MIDDLE NAME* GUIAMEL Chad
25. MOTHER'S MAIDEN NAME* Chile
SURNAME* USOP China
FIRST NAME* SAIDA Colombia
MIDDLE NAME* SALIBO (Continue on separate sheet if necessary) Comoros
III. EDUCATIONAL BACKGROUND Congo, Democratic Re
HIGHEST LEVEL/ SCHOLARSHIP/
Congo, Republic of the
26. NAME OF SCHOOL PERIOD OF ATTENDANCE YEAR
BASIC EDUCATION/DEGREE/COURSE UNITS ACADEMIC
LEVEL (Write in
(Write in full) EARNED
GRADUATED
HONORS Costa Rica
full) (if not graduated) RECEIVED
From To Cote d'Ivoire
SAAVEDRA SAWAY CENTRAL 06-01- 03-31-
ELEMENTARY*
ELEMENTARY SCHOOL 2005 2010
2010 N/A Croatia
06-01- 03-31-
SECONDARY*/
VOCATIONAL LABANGAL NATIONAL HIGH SCHOOL
2010 2014
2014 N/A Cuba
N/A Curacao
TRADE
BACHELOR OF ARTS MAJOR IN 06-01- 06-10-
COURSE
COLLEGE MINDANAO STATE UNIVERSITY-GENSAN
FILIPINO 2014 2019
2019 ESGPPA Cyprus
GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A Czech Republic
(Continue on separate sheet if necessary) Djibouti
SIGNATURE DATE Dominica
CS FORM 212 (Revised 2017), Page 1 of 4 Dominican Republic
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
N/A N/A N/A N/A 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)
07-06-2018 04-08-2018 PRE-SERVICE TEACHING DEPED N/A
03-09-2019 01-03-2020 PLDT AGENT PLDT 4,600
ENUMERATOR PHILIPPINE STATISTICS AUTHORITY 13,000
(Continue on separate sheet if necessary)
SIGNATURE DATE
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
NC II IN DRESS MAKING 05-21-2019 12-17-2019 265 TECHNICAL BROKEN SHIRE COLLEGE GENSAN
SEMINAR NG PANANALIKSIK 02-27-2019 5.0 MINDANAO STATE UNIVERSITY- GENSAN
USWAG DANGAL NG FILIPINO 2019- PAMBANSANG SEMINAR- WORKSHOP SA
02-27-2019 03-03-2019 27.0 GREENLEAF HOTEL GENSAN
PAGSULAT NG KORESPONDENSYA OPISYAL
BRGY. SARAVIA KORONADAL SOUTH
TRAINING OF VOLUNTER TEACHERS 04-29-2018 10.0
COTABATO
(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 in
(Write in full)
full)
DRESS MAKING N/A N/A
COMPUTER LITERATE (MS WORD, EXCEL AND
PPT)
COMMUNICATION SKILL
TIME MANAGEMENT
CAN WORK UNDER PRESSURE
(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, Yes
a. within the third degree?* No
b. within the fourth degree (for Local Government Unit - Career Employees)?*
If YES, give details: Yes
________________________________ No
35. a. Have you ever been found guilty of any administrative offense?*
If YES, give details: Yes
________________________________ No
________________________________
b. Have you been criminally charged before any court?*
If YES, give details: Yes
________________________________
Date Filed: No
________________________________
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?*
If YES, give details: Yes
________________________________ No
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation,
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased If YES, give details: Yes
out (abolition) in the public or private sector?* ________________________________ No
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)?* Yes
If YES, give details:
No
b. Have you resigned from the government service during the three (3)-month period before the last
election to promote/actively campaign for a national or local candidate?* If YES, give details: Yes
No
39. Have you acquired the status of an immigrant or permanent resident of another country?*
If YES, give details (country):
Yes
No
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?*
If YES, please specify: Yes
b. Are you a person with disability?* No
If YES, please specify ID No:
c. Are you a solo parent?* Yes
If YES, please specify ID No: 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
NOEL KINASO SANTOS STREET, COTABATO CITY 9274286234 3.5 cm. X 4.5 cm
(passport size)
DATU COY PIANG COTABATO CITY. 9265955033 With full and handwritten
name tag and signature over
printed name
MAMA SEMA GENSAN CITY. 9169657720
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: * VOTERS ID
ID/License/Passport No.: * 6303024IGL1097FUP10000-3 Signature (Sign inside the box)
Date/Place of Issuance:* GENSAN 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), Page 4 of 4
