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 Ambatan
NAME EXTENSION (JR., SR)
FIRST NAME Leticia

MIDDLE NAME Rico

3. DATE OF BIRTH
(mm/dd/yyyy) 3/14/1988 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH Bangar, La Union If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS
Widowed Separated House/Block/Lot No. Street
Lot. 2 Blk. 2 P. Lucas
Other/s:
Subdivision/Village Barangay
Balubaran, Malinta
7. HEIGHT (m) 1.575 meteres
City/Municipality Province
8. WEIGHT (kg) 52 ZIP CODE Valenzuela City

18. PERMANENT ADDRESS

9. BLOOD TYPE O
House/Block/Lot No. Street

10. GSIS ID NO.

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 913063067944

City/Municipality Province

12. PHILHEALTH NO. 21-050142248-1 ZIP CODE 1440

13. SSS NO. 34-1040308-7 19. TELEPHONE NO.

14. TIN NO. 401 865 794 20. MOBILE NO. 09678034645

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) Jaecia08@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) N/A
FIRST NAME N/A

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME Ambatan

NAME EXTENSION (JR., SR)
FIRST NAME Francisco

MIDDLE NAME Macanas

25. MOTHER'S MAIDEN NAME

SURNAME Rico

FIRST NAME Teresita

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

ELEMENTARY Malinta Elementary School 2001

SECONDARY
VOCATIONAL / Malinta National Highschool 2005

TRADE
COURSE
COLLEGE Our Lady of Fatima University Midwife 2007

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE July 16, 2021

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

(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
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)

11/12/2009 12/28/2009 Promodiser Marjorie's Cakes and Cookies 9500.00 Seasonal No

3/18/2011 11/20/2011 Account Executive (Agent) Jham Manpower Services (Sky Cable) 11000.00 Regular No

3/12/2015 2/15/2015 Receptionist/ Telephone Operator He-Max Industrial Corporation 12000.00 Regular No
 (Continue on separate sheet if necessary)

SIGNATURE DATE July 16, 2021

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

(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

Latest Trends And Issue in Family Planning 12/2/2006 12/2/2006 3.0 Our Lady Of Fatima University

Rights Of Women and Children'' and Family Code 12/09/2006 12/09/2006 3.0
Our Lady Of Fatima University

Abortion-Pro-Life (Depend Life) 12/16/2006 12/16/2006 3.0

Our Lady Of Fatima University

Obstetrical Emergencies (Postpartum Hemorrhage) 1/13/2007 1/13/2007 3.0

Our Lady Of Fatima University

Newborn Care Including Newborn Screening 1/27/2007 1/27/2007 3.0

Our Lady Of Fatima University

Integrated Midwives Associations of Philippine Incorporation 2/16/2007 2/16/2007 3.0

Our Lady Of Fatima University

Dangers of STD, HIV and AIDS 2/17/2007 2/17/2007 4.0

Our Lady Of Fatima University

(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)

Hiking
 Drawing

Painting

(Continue on separate sheet if necessary)

SIGNATURE DATE July 16, 2021

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 ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘

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
the last 6 months
Dianne Alejon Valenzuela City 9488835300 3.5 cm. X 4.5 cm
(passport size)

Dianne Rose De Guzman Sta. Quiteria (Caloocan) 9083027234 With full and handwritten
name tag and signature over
printed name
Jun-Jun Concepcion Potrero Malabon 9338193585
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: UMID/ CRN- 0111-3998447-8
ID/License/Passport No.:
Signature (Sign inside the box)
July 16, 2021
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