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 HIBLAWAN

FIRST NAME JANICE NAME EXTENSION (JR., SR)

MIDDLE NAME BOLLA

3. DATE OF BIRTH
16. CITIZENSHIP Filipino Dual Citizenship
(mm/dd/yyyy) ✘

AUGUST 24,1990 by
✘ by naturalization
birth
4. PLACE OF BIRTH UMALBONG HINGYON IFUGAO If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRES

Widowed Separated House/Block/Lot No. Street
UMALBONG
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 1.651M HINGYON IFUGAO
City/Municipality Province
8. WEIGHT (kg) 70KG ZIP CODE 3607

9. BLOOD TYPE O 18. PERMANENT ADDRES

House/Block/Lot No. Street
10. GSIS ID NO. N/A UMALBONG
Subdivision/Village Barangay
HINGYON IFUGAO
11. PAG-IBIG ID NO. N/A
City/Municipality Province
12. PHILHEALTH NO. N/A ZIP CODE 3607

13. SSS NO. N/A 19. TELEPHONE NO.

14. TIN NO. 47302207300 20. MOBILE NO. 0350243001/ 09480099628

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if an janicehiblawan30@gmail.com

II. FAMILY BACKGROUND

DATE OF BIRTH
22. SPOUSE'S SURNAME HIBLAWAN 23. NAME of CHILDREN (Write full name and list all)
(mm/dd/yyyy)
FIRST NAME JONAS NAME EXTENSION (JR., HEINZ KIM B. HIBLAWAN JANUARY 21,2009
SR)
MIDDLE NAME LUGMAYO HUILIER B. HIBLAWAN AUGUST 6,2010

OCCUPATION GOVERNMENT EMPLOYEE HEINDRIX B. HIBLAWAN DECEMBER 12,2015

EMPLOYER/BUSINESS NAM PHILIPPINE NATIONAL POLICE

BUSINESS ADDRESS KIANGAN POLICE STATION

TELEPHONE NO. 9350911412

24.FATHER'S SURNAME BOLLA

FIRST NAME EDUARD NAME EXTENSION (JR.,

SR)
MIDDLE NAME BUBOD

25. MOTHER'S MAIDEN NAME GANO

SURNAME BOLLA

FIRST NAME JANILYN

MIDDLE NAME GONGOB (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

ELEMENTARY UMALBONG ELEMENTARY SCHOOL GRADE 1 1/5/1900 2003

SECONDARY /
VOCATIONAL DON BOSCO HIGH SCHOOL 1ST YEAR 4TH YEAR 2007

TRADE
COURSE
COLLEGE IFUGAO STATE UNIVERSITY BATCHELOR OF SCIENCE IN CRIMINOLOGY 1ST YEAR 4TH YEAR 2015

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE JUNE 14,2022

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
OCTOBER 17-19 AUGUST
BOARD ELIGIBILITY 2015
BAGUIO CITY 0131642 24,2025

DRIVERS LICENSE LAMUT IFUGAO PO2-17-001506 8/24/2024

(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)
BARANGAY UMALBONG LOCAL HONORARI
SANGUNIANG KABATAAN CHAIRMAN ELECTED Y
GOVERNMENT UNIT UM

(Continue on separate sheet if necessary)

SIGNATURE DATE JUNE 14 2022

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

BASIC ECCLESIAL COMMUNITY EDUCATION MINISTRY

INTUGAR GOGO IRRIGATORS ASSOCIATION TREASURER

EASTERN FARMERS ORGANIZATION VICE PRESIDENT

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
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

LEADERSHIP TRAINING AND FINANCIAL LITERACY SEMINAR AND WORKSHOP 6/13/2009 14 2009 16 HOURS BARANGAY UMALBONG

OPERATION AND MAINTENANCE PLANNING 4/16/2022 17 2009 16 HOURS NATIONAL IRRIGATION ADMINISTRATION

(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)

NONE NONE

PUBLIC SPEAKING BASIC ECCLESIAL COMMUNITY

VOLLEYBALL INTUGAR GOGO IRRIGATORS ASSOCIATION

COOKING EASTERN FARMERS ORGANIZATION

DANCING

(Continue on separate sheet if necessary)

SIGNATURE DATE JUNE 14,2022

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: TUWAL
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
JIMMY LANGBAYAN UMALBONG HINGYON IFUGAO 9531453339 4.5 cm. X 3.5 cm
(passport size)

CLARITA BINUGGON LAGAWE IFUGAO 9971566177

Computer generated
or photocopied picture
is not acceptable

42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and
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: PRC

ID/License/Passport No.: 0131642

Signature (Sign inside the box)
JUNE 14 2022
Date/Place of Issuance: 6/17/20126
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