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 JALAPIT
NAME EXTENSION (JR., SR) N/A
FIRST NAME NIKKE JOY

MIDDLE NAME TAG-AT

3. DATE OF BIRTH
05/04/1992 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH PANAON If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS N/A PUROK 7

Widowed House/Block/Lot No. Street

Separate
N/A POBLACION
Other/s: d
Subdivision/Village Barangay
PANAON MISAMIS OCCIDENTAL
7. HEIGHT (m) 1.50m
City/Municipality Province
8. WEIGHT (kg) 47.5kg ZIP CODE 7205

18. PERMANENT ADDRESS N/A PUROK 7

9. BLOOD TYPE "O"
House/Block/Lot No. Street
N/A POBLACION
10. GSIS ID NO. N/A
Subdivision/Village Barangay
PANAON MISAMIS OCCIDENTAL
11. PAG-IBIG ID NO. 1211-1365-6434
City/Municipality Province

12. PHILHEALTH NO. 03-051177580-5 ZIP CODE 7205

13. SSS NO. 34-4277064-9 19. TELEPHONE NO. (088)521-4885

14. TIN NO. 317-086-909 20. MOBILE NO. 0977-134-2083

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

FIRST NAME N/A

NAME EXTENSION (JR., SR) NIKKAH GLODEZZA ESPARRAGO 09/02/2015
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 JALAPIT

NAME EXTENSION (JR., SR) N/A
FIRST NAME NESTOR

MIDDLE NAME OMPOCO

25. MOTHER'S MAIDEN NAME

SURNAME TAG-AT

FIRST NAME EVANGELINE

MIDDLE NAME BAJAMONDE (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY PANAON CENTRAL SCHOOL ELEMENTARY 1998 2004 GRADUATED 2004 FIFTH HONORS

VOCATIONAL /
SECONDARY PANAON COMMUNITY HIGH SCHOOL HIGH SCHOOL 2004 2008 GRADUATED 2008 SALUTATORIAN

N/A N/A N/A N/A N/A N/A N/A

TRADE
COURSE BACHELOR OF SCIENCE IN BUSINESS
COLLEGE LA SALLE UNIVERSITY-OZAMIS CITY
ADMINISTRATION-MARKETING MANAGEMENT
2010 2013 GRADUATED 2013 N/A

GRADUATE STUDIES LA SALLE UNIVERSITY-OZAMIS CITY MASTER IN PUBLIC ADMINISTRATION 2021 2021 12 UNITS N/A N/A

SIGNATURE DATE 10/12/2022

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

LICENSURE EXAMINATION FOR TEACHERS 83.60 09/26/2021 PAGADIAN CITY 1890984 05/04/2025

(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)
UNIVERSITY OF SCIENCE AND TECHNOLOGY OF
08/25/2020 05/28/2021 INSTRUCTOR
SOUTHERN PHILIPPINES-PANAON CAMPUS
12,624.00 N/A CONTRACTUAL Y

UNIVERSAL STOREFRONT SERVICES CORPORATION-

03/05/2014 11/01/2016 CUSTOMER SERVICE REPRESENTATIVE
QUEZON CITY
10,000.00 N/A PERMANENT N

(Continue on separate sheet if necessary)

SIGNATURE DATE 10/12/2022

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 NUMBER OF
(Write in full) (mm/dd/yyyy) 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
INCLUSIVE DATES OF
ATTENDANCE Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS NUMBER OF ( Managerial/ CONDUCTED/ SPONSORED BY
(Write in full) HOURS Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To

COMPUTER LITERACY PROGRAM 01/10/2022 01/21/2022 100 TECHNICAL ILIGAN COMPUTER INSTITUTE-KAPATAGAN

DEPARTMENT OF INFORMATION AND COMMUNICATIONS

DIGITAL TRANSFORMATION TECHNOLOGIES TRAINING 12/14/2021 12/15/2021 9 TECHNICAL
TECHNOLOGY
UNIVERSITY OF SCIENCE AND TECHNOLOGY OF SOUTHERN
FACULTY BOOTCAMP TEACHING TECH 101 RELATED ENTREPRENEURSHIP COURSES 05/25/2021 05/27/2021 24 TECHNICAL
PHILIPPINES

WEALTH BUILDING & FINANCIAL LITERACY TRAINING FOR TEACHERS 02/09/2021 02/09/2021 4 TECHNICAL PAGLAUM MULTIPURPOSE COOPERATIVE

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION 33.MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32.
(Write in full) (Write in full)

COMPUTER SKILLS COLLEGE OFFICER N/A

INTERPERSONAL COMMUNICATION

ORGANIZATIONAL

MULTITASKING

CUSTOMER SERVICE

SINGING

PLAYING BADMINTON
(Continue on separate sheet if necessary)

SIGNATURE DATE 10/12/2022

 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 by any
YES ✘ NO
court or tribunal?
If YES, give details:
________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation, retirement, ✘ YES NO
dropped from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in the If YES, give details:
public or private sector? ________________________________
RESIGNATION
________________________________
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
UNIVERSITY OF SCIENCE AND TECHNOLOGY OF SOUTHERN the last 6 months
DR. LENY Q. AÑASCO PHILIPPINES-PANAON
0975 261 4958 4.5 cm. X 3.5 cm
(passport size)

UNIVERSITY OF SCIENCE AND TECHNOLOGY OF SOUTHERN

JETHRA M. LAPINIG PHILIPPINES-PANAON
0907 109 3577 Computer generated
or photocopied picture
UNIVERSAL STOREFRONT SERVICES CORPORATION- is not acceptable
ARJEAN AGOR QUEZON CITY
929-7644
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 administrative/criminal case/s PHOTO
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.: 1890984 Signature (Sign inside the box)

10/12/2022
Date/Place of Issuance: 02/02/2022-PAGADIAN 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