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 CAYAT
NAME EXTENSION (JR., SR)
FIRST NAME CYNTHIA

MIDDLE NAME MAGTAOS

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 7/16/1997 ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH STA. INES, TANAY, RIZAL If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS 143 Saint Agnes

Widowed Separated House/Block/Lot No. Street

Sta. Ines
Other/s: Subdivision/Village Barangay
Tanay Rizal
7. HEIGHT (m) 1.54
City/Municipality Province
8. WEIGHT (kg) 49 ZIP CODE 1980

18. PERMANENT ADDRESS 143 Saint Agnes

9. BLOOD TYPE O
House/Block/Lot No. Street
Sta. Ines
10. GSIS ID NO.
Subdivision/Village Barangay
Tanay Rizal
11. PAG-IBIG ID NO.
City/Municipality Province

12. PHILHEALTH NO. 03-026443221-5 ZIP CODE 1980

13. SSS NO. 34-8639147-9 19. TELEPHONE NO.

14. TIN NO. 753-053-511-000 20. MOBILE NO. 09124872156

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) cynthcayat@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME N/A N/A
MIDDLE NAME
OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS
TELEPHONE NO.

24. FATHER'S SURNAME CAYAT 12/29/1964

NAME EXTENSION (JR., SR)
FIRST NAME ARMANDO

MIDDLE NAME PIMENTEL

25. MOTHER'S MAIDEN NAME

SURNAME MAGTAOS 10/14/1964

FIRST NAME GINA

MIDDLE NAME SALVADOR (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

STA. INES ELEMENTARY SCHOOL ELEMENTARY GRADUATE 2004 2010 2010 SALUTATORIAN
ELEMENTARY

SECONDARY /
VOCATIONAL STA. INES NATIONAL HIGH SCHOOL HIGH SCHOOL GRADUATE 2010 2014 2015 SALUTATORIAN

TRADE
BACHELOR OF SCIENCE IN AGRICULTURAL
COURSE
COLLEGE UNIVERSITY OF RIZAL SYSTEM TANAY CAMPUS
ENGINEERING
2014 2019 2019

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE October 9, 2020

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

IV. CIVIL SERVICE ELIGIBILITY
27. LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT Date of
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
SERVICE
28. INCLUSIVE DATES SALARY/ JOB/ PAY
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY GRADE (if applicable)& STATUS OF
(Write in full/Do not (Write in SALARY STEP (Format "00-0")/ APPOINTMENT
abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)
9/5/2019 3/1/2020 Customer Representative The Results Company 15,000.00 N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 10/09/2020

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
SKILLS ON TRAINING ON THE OPERATION OF LAND PREPARATION OF
MACHINERIES FOR THE MECHANIZED RICE PRODUCTION
8/30/2018 8/31/2018 16.00 N/A N/A

KNOWLEDGE AND SHARING AND LEARNING ON AGRICULTURE AND FISHERIES OR 10/3/2017 10/5/2017 8.0 N/A

(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)
PHILIPPINE SOCIETY OF AGRICULTURE
PLANTING BADAC(Barangay Anti-Drug Abuse Committee) Youth Representatine
ENGINEERS
HIKING Ynares Youth Grantee

PLAYING ONLINE CHESS

(Continue on separate sheet if necessary)

SIGNATURE DATE 10/9/2020

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 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: Remontado(Dumagat)
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
Editha De Duzman Tanay,Rizal 3.5 cm. X 4.5 cm
(passport size)

With full and handwritten

name tag and signature over
printed name

Computer generated
42. or photocopied picture
I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and 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: n/a

ID/License/Passport No.: n/a

Signature (Sign inside the box)

Date/Place of Issuance: n/a

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