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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
________________________________
________________________________
35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court?
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 court or tribunal?
If YES, give details:
________________________________

37. Have you ever been separated from the service in any of the following modes: resignation,
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
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the
last 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?
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?
If YES, please specify:
b. Are you a person with disability?
If YES, please specify ID No:
c. Are you a solo parent?
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
ALICIA D. PALMERO BRGY. SAN JOAQUIN MARIA AURORA 3.5 cm. X 4.5 cm
(passport size)

MAY ANN GONZALES-CASTRO BRGY. FLORIDA With full and handwritten

name tag and signature over
printed name
PSSG. ALVIN I. DE GUZMAN KABIRAN,SUKLAYIN BALER AURORA
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:

ID/License/Passport No.:
Signature (Sign inside the box)
P
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

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

N/A N/A N/A N/A N/A 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)

ATTENTION TO DETAIL

COLLABORATION & TEAMWORK

CREATIVITY & INNOVATION

(Continue on separate sheet if necessary)

SIGNATURE DATE January 4, 2021 CS FORM 212 (Revised 2017), Page 3 of 4

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER RATING DATE OF LICENSE (if applicable)
SPECIAL LAWS/ CES/ CSEE (If EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE Applicable) CONFERMENT
Validity

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

LICENSED PROFESSIONAL TEACHER 82.4 OCTOBER 02,2021 BAGUIO CITY

NAPOLCOM PASSER 78.8 APRIL 09,2021 BAGUIO CITY

(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
INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
28. POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) GRADE (if
MONTHLY STATUS OF
applicable)& STEP
SALARY (Format "00-0")/ APPOINTMENT
(Write in full/Do not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To
(Y/ N)
LOCAL GOVERNMENT UNIT/MUNICIPAL
3/1/2021 1/7/2021 ADMINISTRATIVE AIDE 6,000.00 JOB ORDER YES
SOCIAL WELFARE AND DEVELOPMENT
LOCAL GOVERNMENT UNIT/MUNICIPAL
1/3/2020 7/31/2020 ADMINISTRATIVE AIDE 6,000.00 JOB ORDER YES
SOCIAL WELFARE AND DEVELOPMENT
LOCAL GOVERNMENT UNIT/MUNICIPAL
3/9/2019 12/29/2019 ADMINISTRATIVE AIDE 6,000.00 JOB ORDER YES
SOCIAL WELFARE AND DEVELOPMENT

(Continue on separate sheet if necessary)

SIGNATURE DATE CS FORM 212 (Revised 2017), Page 2 of 4

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

MIDDLE NAME GUERZON

3. DATE OF BIRTH
(mm/dd/yyyy) 11/17/1995 16. CITIZENSHIP FILIPINO

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

please indicate the details.
5. SEX FEMALE
17. RESIDENTIAL ADDRESS
6 CIVIL STATUS SINGLE
House/Block/Lot No. Street
PUROK-4 SAN JOAQUIN
Subdivision/Village Barangay
7. HEIGHT (m) 5'2 MARIA AURORA AURORA
City/Municipality Province
8. WEIGHT (kg) 59 ZIP CODE 3202
18. PERMANENT ADDRESS
9. BLOOD TYPE A
House/Block/Lot No. Street

10. GSIS ID NO. N/A PUROK-4 SAN JOAQUIN

Subdivision/Village

11. PAG-IBIG ID NO. N/A MARIA AURORA AURORA

City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 3202

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

14. TIN NO. N/A 20. MOBILE NO. 09707116854

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) ENINAJGONZALES3@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 ZACH ISRAEL GONZALES 8/5/2019
MIDDLE NAME N/A
OCCUPATION N/A
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME GONZALES
NAME EXTENSION (JR., SR)
FIRST NAME JIMMY N/A
MIDDLE NAME BALANGUE
25. MOTHER'S MAIDEN NAME GUERZON
SURNAME DELA CRUZ
FIRST NAME JOSEFINA
MIDDLE NAME MAMARADLO (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
(Write in full) HONORS
full) (if not graduated) RECEIVED
From To

ELEMENTARY LEON DIAZ SR. ELEM PRIMARY EDUCATION 2006 2012 GRADUATED 2012 NONE

SECONDARY /
VOCATIONAL MARIA AURORA NATIONAL HIGH SCHOOL HIGH SCHOOL 2012 2016 GRADUATED 2016 NONE

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

TRADE
COURSE WESLEYAN UNIVERSITY PHILIPPINES- BACHELOR IN ELEMENTARY
COLLEGE 2017 2021 N/A 2021 NONE
AURORA EDUCATION

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

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

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

MIDDLE NAME GUERZON

3. DATE OF BIRTH
(mm/dd/yyyy) 11/17/1995 16. CITIZENSHIP FILIPINO

4. PLACE OF BIRTH BALER AURORA, AURORA If holder of dual citizenship,

please indicate the details.

5. SEX FEMALE

17. RESIDENTIAL ADDRESS

6 CIVIL STATUS SINGLE
House/Block/Lot No. Street
PUROK-4 SAN JOAQUIN
Subdivision/Village Barangay
7. HEIGHT (m) 5'2 MARIA AURORA AURORA
City/Municipality Province
8. WEIGHT (kg) 59 ZIP CODE 3202
18. PERMANENT ADDRESS
9. BLOOD TYPE A
House/Block/Lot No. Street

10. GSIS ID NO. N/A PUROK-4 SAN JOAQUIN

Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A MARIA AURORA AURORA

City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 3202

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

14. TIN NO. N/A 20. MOBILE NO. 09707116854

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) ENINAJGONZALES3@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 ZACH ISRAEL GONZALES 8/5/2019
MIDDLE NAME N/A
OCCUPATION N/A
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME GONZALES 5/2/1972
NAME EXTENSION (JR., SR)
FIRST NAME JIMMY N/A
MIDDLE NAME BALANGUE
25. MOTHER'S MAIDEN NAME GUERZON
SURNAME DELA CRUZ 9/29/1975

FIRST NAME JOSEFINA

MIDDLE NAME MAMARADLO (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
(Write in full) HONORS
full) (if not graduated) RECEIVED
From To

ELEMENTARY LEON DIAZ SR. ELEMENTARY SCHOOL PRIMARY EDUCATION 2007 2012 GRADUATED 2012 NONE

SECONDARY /
VOCATIONAL MARIA AURORA NATIONAL HIGH SCHOOL HIGH SCHOOL 2013 2016 GRADUATED 2016 NONE

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

TRADE
COURSE WESLEYAN UNIVERSITY PHILIPPINES- BACHELOR OF SCIENCE IN
COLLEGE 2017 2021 GRADUATED 2021 NONE
AURORA ELEMENTARY EDUCATION

GRADUATE STUDIES

(Continue on separate sheet if necessary)

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

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER RATING DATE OF LICENSE (if applicable)
SPECIAL LAWS/ CES/ CSEE (If EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE Applicable) CONFERMENT
Validity

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
INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
28. POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) GRADE (if
MONTHLY STATUS OF
applicable)& STEP
SALARY (Format "00-0")/ APPOINTMENT
(Write in full/Do not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To
(Y/ N)

1/3/2022 PRESENT ADMIN AIDE LGU MARIA AURORA 6,000.00

1/4/2021 12/31/2021 ADMIN AIDE LGU MARIA AURORA 6,000.00

1/2/2020 6/30/2020 ADMIN AIDE LGU MARIA AURORA 6,000.00

7/4/2019 12/30/2019 ADMIN AIDE LGU MARIA AURORA 6,000.00

9/8/2017 2/10/2018 PUREGOLD SUPERMARKET SC JOHNSON COMPANY 14,000.00

1/3/2017 6/3/2017 ROBINSON SUPERMARKET ROBINSON TAGAYTAY 11,000.00

(Continue on separate sheet if necessary)

SIGNATURE DATE January 3, 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

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

(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)

COMPUTER LITERATE

SOCIAL ACTIVITIES

(Continue on separate sheet if necessary)

SIGNATURE DATE January 3, 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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
________________________________
________________________________
35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court?
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 court or tribunal?
If YES, give details:
________________________________

37. Have you ever been separated from the service in any of the following modes: resignation,
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? ________________________________
RESIGNATION/FINISHED CONTRACT
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the
last 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?
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?
If YES, please specify:
b. Are you a person with disability?
If YES, please specify ID No:
c. Are you a solo parent?
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
ROSE FABROS BRGY. DIAAT MARIA AURORA 9277652930 3.5 cm. X 4.5 cm
(passport size)

FEDERICO ESTACIO BRGY. DIAAT MARIA AURORA 9187069514 With full and handwritten
name tag and signature over
printed name
MARY GRACE DE GUZMAN BRGY. DIAAT MARIA AURORA 9067754821
Computer generated
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 against me.
or photocopied picture
is not acceptable

PHOTO

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of Issuance
Government Issued ID:

ID/License/Passport No.:
Signature (Sign inside the box)
January 3, 2022
Date/Place of Issuance: 1/ 1/19- MARIA AURORA
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

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

MIDDLE NAME GUERZON

3. DATE OF BIRTH
(mm/dd/yyyy) 11/17/1995 16. CITIZENSHIP PHILIPPINES
FILIPINO

4. PLACE OF BIRTH MARIA AURORA, AURORA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX FEMALE
17. RESIDENTIAL ADDRESS
6 CIVIL STATUS SINGLE
House/Block/Lot No. Street
PUROK 4 SAN JOAQUIN
Subdivision/Village Barangay
7. HEIGHT (m) 5'2" MARIA AURORA AURORA
City/Municipality Province
8. WEIGHT (kg) 64 ZIP CODE 3202
18. PERMANENT ADDRESS
9. BLOOD TYPE A
House/Block/Lot No. Street

10. GSIS ID NO. N/A PUROK 4 SAN JOAQUIN

Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A MARIA AURORA AURORA

City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 3202

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

14. TIN NO. N/A 20. MOBILE NO. 09703254639

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) matikas253873@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 ZACH ISRAEL GONZALES 8/5/2019

MIDDLE NAME N/A
OCCUPATION N/A
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME DECEASED
FIRST NAME "
MIDDLE NAME "
25. MOTHER'S MAIDEN NAME GUERZON
SURNAME GONZALES
FIRST NAME JOSEPHINE
MIDDLE NAME DELA CRUZ (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
(Write in full) HONORS
full) (if not graduated) RECEIVED
From To

ELEMENTARY LEON DIAZ SR. ELEMENTARY SCHOOL PRIMARY EDUCATION 2007 2012 GRADUATED 2012 NONE

SECONDARY
VOCATIONAL / MARIA AURORA NATIONAL HIGH SCHOOL HIGH SCHOOL 2012 2015 GRADUATED 2015 NONE

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

TRADE
COURSE WESLEYAN UNIVERSITY PHILIPPINES- BEED- MAJOR IN GENERAL
COLLEGE 2 016 2021 GRADUATED 2021 NONE
AURORA EDUCATION

GRADUATE STUDIES ELEMENTARY EDUCATION

(Continue on separate sheet if necessary)

SIGNATURE DATE January 3, 2022 CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER RATING DATE OF LICENSE (if applicable)
SPECIAL LAWS/ CES/ CSEE (If EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE Applicable) CONFERMENT
Validity

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
INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
28. POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) GRADE (if
MONTHLY STATUS OF
applicable)& STEP
SALARY (Format "00-0")/ APPOINTMENT
(Write in full/Do not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To
(Y/ N)

PRESENT ADMIN.AIDE LGU MARIA AURORA P6,000

1/1/2021 12/31/2021 ADMIN.AIDE LGU MARIA AURORA P6,000

1/1/2020 12/31/2020 ADMIN.AIDE LGU MARIA AURORA P6,000

1/1/2019 12/31/2019 ADMIN.AIDE LGU MARIA AURORA P6,000

1/1/2018 12/31/2018 ADMIN.AIDE LGU MARIA AURORA P5,500

1/1/2017 12/31/2017 ADMIN.AIDE LGU MARIA AURORA P5,500

1/1/2016 12/31/2016 ADMIN.AIDE LGU MARIA AURORA P5,500

10/1/2014 11/15/2016 ROOM STEWARD/ WAITER HOTEL SOGO (S17 BANAWE) P12,250

10/1/20113 4/1/2013 ELECTRIC FAN PRODUCTION MACLIN ELECTRONICS P10,000

3/27/2012 7/27/2012 FOOD PRODUCTION JOE KUANFOOD CORPORATION P12,000

(Continue on separate sheet if necessary)

SIGNATURE DATE January 3, 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

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

(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)

COMPUTER LITERATE

SOCIAL ACTIVITIES

(Continue on separate sheet if necessary)

SIGNATURE DATE January 3, 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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
________________________________
________________________________
35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court?
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 court or tribunal?
If YES, give details:
________________________________

37. Have you ever been separated from the service in any of the following modes: resignation,
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? ________________________________
RESIGNATION/FINISHED CONTRACT
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the
last 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?
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?
If YES, please specify:
b. Are you a person with disability?
If YES, please specify ID No:
c. Are you a solo parent?
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
MELANIE R. BARNAYHA BRGY.DIOME, MARIA AURORA 0909-2243092 3.5 cm. X 4.5 cm
(passport size)

IMELDA M. ABENOJAR BRGY.DIOME, MARIA AURORA 0910-3356305 With full and handwritten
name tag and signature over
printed name
JOSE MOLINA BELMONTE BRGY.DIOME, MARIA AURORA 0909-6048936
Computer generated
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 against me.
or photocopied picture
is not acceptable

PHOTO

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of Issuance
Government Issued ID: 03340245

ID/License/Passport No.: 20897682

Signature (Sign inside the box)
January 3, 2022
Date/Place of Issuance: 1/ 1/19- MARIA AURORA
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

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

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

MIDDLE NAME

3. DATE OF BIRTH
(mm/dd/yyyy) 8/7/1989 16. CITIZENSHIP

4. PLACE OF BIRTH MANDALUYONG CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX FEMALE
17. RESIDENTIAL ADDRESS
6 CIVIL STATUS MARRIED
House/Block/Lot No. Street
PUROK MALIGAYA QUIRINO
Subdivision/Village Barangay
7. HEIGHT (m) 1.49 MARIA AURORA AURORA
City/Municipality Province
8. WEIGHT (kg) 44 KG. ZIP CODE 3202
18. PERMANENT ADDRESS
9. BLOOD TYPE A
House/Block/Lot No. Street

10. GSIS ID NO. N/A PUROK MALIGAYA QUIRINO

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121184212126 MARIA AURORA AURORA

City/Municipality Province

12. PHILHEALTH NO. 212002800990 ZIP CODE 3202

13. SSS NO. 0241479322 19. TELEPHONE NO. N/A

14. TIN NO. 737-380-146-000 20. MOBILE NO. 09073649588

15. AGENCY EMPLOYEE NO. JO-16-028 21. E-MAIL ADDRESS (if any) harkin_23@yahoo.com

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME JACINTO 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

NAME EXTENSION (JR., SR) N/A

FIRST NAME HARVY MARK RYVEN S. JACINTO 1/13/2010
MIDDLE NAME RONGUILLO
OCCUPATION J&T SPRINTER
EMPLOYER/BUSINESS NAME J&T EXPRESS
BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME SATURNO ( DECEASED )

NAME EXTENSION (JR., SR)
FIRST NAME RODOLFO N/A
MIDDLE NAME DOGAY
25. MOTHER'S MAIDEN NAME

SURNAME PAURILLO
FIRST NAME LEONORA
MIDDLE NAME HAYOPILLIN (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
(Write in full) HONORS
full) (if not graduated) RECEIVED
From To

ELEMENTARY PEMBO ELEMENTARY SCHOOL PRIMARY EDUCATION 1997 2003 GRADUATED 2003 NONE

ELISEO C. RONQUILLO SR. MEMORIAL

SECONDARY /
VOCATIONAL SECONDARY 2004 2007 GRADUATED 2008 NONE
NATIONAL HIGH SCHOOL

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

TRADE
COURSE
COLLEGE N/A N/A N/A N/A N/A N/A N/A

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 4, 2021 CS FORM 212 (Revised 2017), Page 1 of 4