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 BACLIG
NAME EXTENSION (JR., SR)
FIRST NAME LORNA

MIDDLE NAME GABON

3. DATE OF BIRTH
(mm/dd/yyyy) 08/12/1999 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH DIPACULAO, AURORA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS ✘ Single Married

17. RESIDENTIAL ADDRESS 42 FERNANDEZ
House/Block/Lot No. Street
Widowed Separated
PUROK 2 LABOY
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 1.68 DIPACULAO AURORA
City/Municipality Province
8. WEIGHT (kg) 68 ZIP CODE

9. BLOOD TYPE N/A

18. PERMANENT ADDRESS 42 FERNANDEZ
House/Block/Lot No. Street

10. GSIS ID NO. N//A PUROK 2 LABOY

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121312851735 DIPACULAO AURORA

City/Municipality Province

12. PHILHEALTH NO. ZIP CODE

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 619-401-934-00000 20. MOBILE NO. 09105059114

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any)

gabonbaclig@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

JR
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME BACLIG

FIRST NAME FLORENTINO

MIDDLE NAME ORPIANO

25. MOTHER'S MAIDEN NAME

SURNAME GABON

FIRST NAME CEFERINA

MIDDLE NAME ANTONIO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY LABOY ELEMENTARY SCHOOL 2006 2012 2012 SALUTATORIAN

DIPACULAO NATIONAL HIGH SCHOOL JUNIOR HIGH SCHOOL 2012 2016 2016 SALUTATORIAN
SECONDARY /
VOCATIONAL
CENTRAL LUZON STATE UNIVERSITY SENIOR HIGH SCHOOL 2016 2018 2018 WITH HONORS

TRADE ACADEMIC
BACHELOR OF SCIENCE IN CIVIL
COURSE
COLLEGE CENTRAL LUZON STATE UNIVERSITY
ENGINEERING
2018 2022 15-Jul-22 EXCELLENCE
AWARDEE

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE June 27, 2023

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
CIVIL ENGINEERING LICENSURE EXAMINATION NOVEMBER 19-20,
72.0 2022
BAGUIO CITY, BENGUET 0191749 8/12/2026
PASSER

(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
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To
(Y/ N)
02/06/2023 06/30/2023 JOB ORDER LGU DIPACUALAO- MAYOR'S OFFICE 8,000.00 N/A CONTRACTUAL Y

(Continue on separate sheet if necessary)

SIGNATURE DATE 6/27/2023

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) HOURS POSITION / NATURE OF WORK
(mm/dd/yyyy)
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 NUMBER OF ( Managerial/ CONDUCTED/ SPONSORED BY
(Write in full) (mm/dd/yyyy)
HOURS Supervisory/ (Write in full)
Technical/etc)
From To
CONSTRUCTION OCCUPATIONAL SAFETY AND HEALTH (COSH) WITH 2 – HOUR FRREAL OCCUPATIONAL HEALTH AND SAFETY TRAINING
10/5/2019 10/13/2019 40 HRS. SAFETY OFFICER 2
TRAINING OF TRAINER SERVICES DEPARTMENT OF LABOR AND EMPLOYMENT
STAAD.PRO CONNECT EDITION: FUNDAMENTALS FOR BEGINNERS WITH XSTRUCTURES - PRC ACCREDITED CPD
3/12/2022 3/13/2023 16 HRS.
INTRODUCTION TO STAAD ADVANCED CONCRETE DESIGN (SACD RCDC) PROVIDER
EFFECTIVE CONSTRUCTION PROJECT PLANNING & MANAGEMENT 3/3/2022 3/3/2022 4 HRS. UPSWING LEARNING CENTER
ENGINEERING SEMINAR 2022 ENTITLED “FORGING ALTERNATIVES: BREAKTHROUGHS OF CIVIL ENGINEERING EXECUTIVE ORGANIZATION -
SUSTAINABLE ENGINEERING AMIDST CONTEMPORARY SOCIO – ECONOMIC CHALLENGES”
2/12/2022 2/12/2022 5 HRS. UNIVERSITY OF THE PHILIPPINES LOS BANOS
SATISFACTORY COMPLETED THE SEMINAR ON “NEW TRENDS AND
1/6/2022 1/6/2022 2 HRS. HOLCIM PHILIPPINES INC.
INNOVATIONS IN CONSTRUCTION TECHNOLOGY

(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)

COMPUTER-AIDED DRAFTING/ AUTOCAD SAFETY OFFICER II (COSH)

3D MODELLING USING SKETCH UP

RENDERING AND ANIMATING (LUMION AND
ENSCAPE)
STEEL DESIGNING USING STAAD AND TEKLA
STRUCTURE
ANALYZING STEEL CONNECTION USING IDEA
STATICA AND HILTI PROFIS ANCHOR

(Continue on separate sheet if necessary)

SIGNATURE DATE 6/27/2023

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 ✘ 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
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: BAG-O
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
HON. DANILO A. TOLENTINO-MUNICIPAL MAYOR DIPACULAO AURORA 9190011058 3.5 cm. X 4.5 cm
(passport size)
ALFREDO O. AGUA DIPACULAO, AURORA 9999940103
With full and handwritten
ENGR. EDGAR G. ESPIRITU RIYADH, SAUDI ARABIA 6505372919 name tag and signature over
printed name
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and
Computer generated
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the or photocopied picture
Philippines. I authorize the agency head/authorized representative to verify/validate the contents stated herein. I is not acceptable
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
ID/License/Passport No.: 0191749 Signature (Sign inside the box)
6/27/2023
Date/Place of Issuance: 02/02/2023 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