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 LOMOTOS
NAME EXTENSION (JR., SR)
FIRST NAME GINA

MIDDLE NAME DAAN

3. DATE OF BIRTH
(mm/dd/yyyy) 1/10/1969 16. CITIZENSHIP

4. PLACE OF BIRTH LILO, BANZA BUTUAN CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX

17. RESIDENTIAL ADDRESS

6 CIVIL STATUS
House/Block/Lot No. Street
PUROK 2 BRGY. BONBON
Subdivision/Village Barangay
BUTUAN CITY AGUSAN DEL NORTE
7. HEIGHT (m) 5'5"
8600 City/Municipality Province
8. WEIGHT (kg) 120 LBS. ZIP CODE

18. PERMANENT ADDRESS

9. BLOOD TYPE O
House/Block/Lot No. Street
PIROK 2 BRGY. BONBON
10. GSIS ID NO. N/A
Subdivision/Village Barangay
BUTUAN CITY AGUSAN DEL NORTE
11. PAG-IBIG ID NO. 3101-767379-09
8600 City/Municipality Province

12. PHILHEALTH NO. 18-025109088-0 ZIP CODE

13. SSS NO. 08-0902918-5 19. TELEPHONE NO. N/A

14. TIN NO. 945-112-323 20. MOBILE NO. 09079667407

15. AGENCY EMPLOYEE NO.
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME
FIRST NAME
N/A 21. E-MAIL ADDRESS (if any) N/A
LOMOTOS 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) QUEEN ROSALY D. LOMOTOS
JOSEPH OCT. 20, 1992

MIDDLE NAME CALO ( DECEASED ) PETER ANTHONY JOSEF D. LOMOTOS AUG .30 ,1995

OCCUPATION N/A HAYDEE JEAN D. LOMOTOS AUG .23, 1995

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME DAAN

NAME EXTENSION (JR., SR)
FIRST NAME PEDRO

MIDDLE NAME BACUS

25. MOTHER'S MAIDEN NAME

SURNAME ACOJEDO

FIRST NAME DONATA

MIDDLE NAME DELA TORRE (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY BANZA ELEMENTARY CSHOOL PRIMARY 1981 1982 GRADUATED 1982 N/A

SECONDARY AGUSAN PEQUEÑO BARANGAY HIGH SCHOOL SECONDARY 1985 1986 GRADUATED 1986 N/A

VOCATIONAL / GENERAL RADIO COMMUNICATION

TRADE COURSE
SAINT JOSEPH INSTITUTE OF TECHNOLOGY
OPERATOR ( GRCO ) 1988 1990 GRADUATED 1990 N/A

COLLEGE N/A N/A N/A N/A N/A N/A N/A

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

(Continue on separate sheet if necessary)

SIGNATURE DATE 1/27/2021

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

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

9/1/2018 TO PRESENT CLERK CITY TREASURER'S OFFICE 400/DAY JOB ORDER NO

1/1/2016 8/31/2018 CLERK CITY TREASURER'S OFFICE 310/DAY JOB ORDER NO

7/1/2015 12/31/2015 CLERK CITY TREASURER'S OFFICE 295/DAY JOB ORDER NO

1/1/2015 6/30/2015 CLERK CITY TREASURER'S OFFICE 295/DAY JOB ORDER NO

12/13/2010 12/31/2014 CLERK CITY TREASURER'S OFFICE 268/DAY JOB ORDER NO

5/1/2008 12/12/2010 CLERK CITY TREASURER'S OFFICE 200/DAY JOB ORDER NO

1/1/2008 4/31/2008 CLERK CITY TREASURER'S OFFICE 200/DAY PLANTILLA YES

7/16/2007 12/31/2007 CLERK CITY TREASURER'S OFFICE 200/DAY PLANTILLA YES

5/25/2006 7/15/2006 CLERK CITY TREASURER'S OFFICE 200/DAY JOB ORDER NO

(Continue on separate sheet if necessary)

SIGNATURE DATE 1/27/2021

CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29.
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION
From To

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 Type of LD

30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE ( Managerial/
(mm/dd/yyyy) NUMBER OF HOURS
(Write in full) Supervisory/
Technical/etc)
From To

SLAUGHTERHOUSE ADMINISTRATION INFORMATION SYSTEM (SAIS ) JUNE 18,2007 JUNE 18,2007 8 HOURS TECHNICAL CITY ECO

GENDER OMBUD GUIDELINES AND BASIC OPERATION ON LOCAL TREASURY SERVICE MARCH 24,2018MARCH 24,2018
8 HOURS TECHNICAL
TRAINING

GENDER AND DEVELOPMENT TRAINING OF SELF-AWARENESS AND TIME SEPT.8, 2018 SEPT.8, 2018 8 HOURS TECHNICAL
MANAGEMENT.

GENDER RESPONSIVENESS ON WOMEN, MEN IN POWER AND DECISION MAKING /ON JULY 6,2019 JULY 6,2019 8 HOURS TECHNICAL
PERSONALITY DEVELOPMENT ON THE WORKPLACE TRAINING.

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMB
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE
N / NATURE OF WORK

N/A

CONDUCTED/ SPONSORED BY
(Write in full)

ONOMIC ENTERPRISE DEPARTMENT

CITY TREASURER'S OFFICE

CITY TREASURER'S OFFICE

CITY TREASURER'S OFFICE

BERSHIP IN ASSOCIATION/ORGANIZATION
(Write in full)

N/A

1/27/2021
CS FORM 212 (Revised 2017), Page 3 of 4
 34. Are you related by consanguinity or affinity to the appointing or recommending
chief of bureau or office or to the person who has immediate supervision over you in
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, If YES, give details: ________________________________
finished contract or phased 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
a. the
Are following items:of any indigenous group?
you a member
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 CEL. NO. ID picture taken within

the last 6 months
3.5 cm. X 4.5 cm
SEGUNDENA T. MONDIA PUROK 2 BONBON BUTUAN CITY 9998781861 (passport size)

With full and handwritten

ELEONAR L. BACUS AMPAYON BUTUAN CITY 9507637693 name tag and signature over
printed name
DANILO S. AUTOR FLORIDA BUTUAN CITY 9485793986 Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, or photocopied picture
is not acceptable
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 PHOTO
and its attachments shall cause the filing of 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: PHILHEALTH I.D.

ID/License/Passport No.: 18-025109088-0

Signature (Sign inside the box)
Date/Place of Issuance: BUTUAN CITY 1/27/2021
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

Yes/No Cstat Gender
Yes Single Male
No Married Female
Separated
Widowed