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 COSTINA
GERALD
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME
BENITO
3. DATE OF BIRTH
(mm/dd/yyyy)
16. CITIZENSHIP
X Filipino Dual Citizenship
04/13/1981 by birth by naturalization

4. PLACE OF BIRTH LA TRINIDAD If holder of dual citizenship, Pls. indicate country:

x Male
please indicate the details.
5. SEX Female

6 CIVIL STATUS Single

x Married 17. RESIDENTIAL ADDRESS JF-041, TOYONG
House/Block/Lot No.
LAOYAN STREET
Street
Widowed Separated
Other/s: PICO
Subdivision/Village Barangay
LA TRINIDAD BENGUET
7. HEIGHT (m) 1.78 City/Municipality Province
8. WEIGHT (kg) 80 ZIP CODE 2601
9. BLOOD TYPE 18. PERMANENT ADDRESS JF-041, TOYONG LAOYAN STREET
House/Block/Lot No. Street
PICO
10. GSIS ID NO.
AB Subdivision/Village Barangay

11. PAG-IBIG ID NO. LA TRINIDAD BENGUET

City/Municipality Province

12. PHILHEALTH NO. ZIP CODE

2601
13. SSS NO. 19. TELEPHONE NO.

14. TIN NO.

257-486-564 20. MOBILE NO. 09212077887
15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) khad.kirk@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME KIS-EWEN 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME APRILY KHADRYCK GY K. COSTINA 10/12/2008
MIDDLE NAME FONGWAN KIRK DYLAN K. COSTINA 10/13/2013
OCCUPATION OVERSEAS FILIPINO WORKER
EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS HONG KONG

TELEPHONE NO.

24. FATHER'S SURNAME COSTINA

NAME EXTENSION (JR., SR)
FIRST NAME ENRICO
MIDDLE NAME ANDRES
25. MOTHER'S MAIDEN NAME

SURNAME BENITO
FIRST NAME JENNY
MIDDLE NAME LUIS (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY PICO ELEMENTARY SCHOOL ELEMENTARY 1987 1993 1993

SECONDARY BENGUET NATIONAL HIGH SCHOOL
HIGH SCHOOL 1993 1997 1997
VOCATIONAL /
TRADE COURSE DATA CENTER COLLEGE COMPUTER TECHNICIAN 1997 1998
COLLEGE BAGUIO COLLEGES FOUNDATION BACHELOR OF SCIENCE IN ACCOUNTANCY
1998 2002 2002
GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 1 of 4