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 GOMEZ

FIRST NAME SUSAN

MIDDLE
LOPEZ

NAME
3. DATE OF BIRTH
(mm/dd/yyyy)
01/06/1972 16. CITIZENSHIP
Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH MANILA If holder of dual citizenship, please
Pls. indicate country:
Female indicate the details.
5. SEX Male

Single Married 17. RESIDENTIAL ADDRESS #74

6 CIVIL STATUS
House/Block/Lot No. Street
Widowed Separated
STAR HEIGHT CULIAT
Subdivision/Village Barangay
Other/s:

QUEZON CITY
7. HEIGHT (m) 5'3 City/Municipality Province
ZIP CODE
8. WEIGHT (kg) 132LBS
18. PERMANENT ADDRESS SAME ADRESS ABOVE
9. BLOOD TYPE A+ House/Block/Lot No. Street

10. GSIS ID NO.

Subdivision/Village Barangay
106000955252
11. PAG-IBIG ID NO.
City/Municipality Province

12. PHILHEALTH NO. 19050577720-8

ZIP CODE

13. SSS NO. 33-12419768 19. TELEPHONE NO.

14. TIN NO. 132-656-443 20. MOBILE NO. 09995326824

N/A
15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) Susangomez612@gmail. com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME GOMEZ 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
ARNALDO NAME EXTENSION (JR., SR) CHRISTINE L. GOMEZ 02-06-2006
FIRST NAME
BERNARDEZ CHERYL LOVE GOMEZ 02-18-2006
MIDDLE

NAME
IT SUPPORT SPECIALIST
OCCUPATION
N/A
EMPLOYER/BUSINESS NAME
N/A
BUSINESS ADDRESS
N/A
TELEPHONE NO.

24. FATHER'S SURNAME LOPEZ

NAME EXTENSION (JR., SR)
FIRST NAME RODRIGO

MIDDLE NAME MANALO

25. MOTHER'S MAIDEN NAME

SURNAME JUMAPAO
FIRST NAME FE

MIDDLE NAME DAGATAN (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY SAN FRANCISCO ELEM. SCHOOL ELEMENTARY SCHOOL 1978 1985 N/A 1985 N/A

SECONDARY
SERGIO OSMENA SR. HIGH SCHOOL HIGH SCHOOL 1985 1989 N/A 1989 N/A

VOCATIONAL /
TRADE COURSE
AURELIO VOCATIONAL SCHOOL HAIR SCIENCE 1989 1998 N/A 1998 N/A

BACHELOR OF SCIENCE AND

COLLEGE
PHILIPPINE SCHOOL BUSINESS ADMI 1998 2004 N/A 2004 N/A
BUSINESS ADMINISTRATION
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 DATE OF LICENSE (if applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION PLACE OF EXAMINATION / CONFERMENT Date of
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE / Validity
CONFERMENT

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

01 06 2022 present LIBRARIAN AIDE SCHOOL DIVISION OFFICE NCR 13,500

N/A
CONTRACTUAL NO
SAN JOSE HIGH SCHOOL

01 06 2021 10-06-2022 LIBRARIAN AIDE SCHOOL DIVISION OFFICE NCR 13,000

N/A
CONTRACTUAL NO
SAN JOSE HIGH SCHOOL

01 06 2020 10-06-2021 LIBRARIAN AIDE SCHOOL DIVISION OFFICE NCR 13,000

N/A
CONTRACTUAL NO
SAN JOSE HIGH SCHOOL

06-15-2009 12-12-2014 ASSISTANT TEACHER TALENT INTERNATIONAL AND THE INFANT 27,000.00 N/A REGULAR NO
SCHOOL BAHRAIN

02 22 -1994 06-21- 2007 PARTS AND SERVICE TOYOTA BALINTAWAK INC. 20,000.00
N/A
REGULAR NO
RECEIVABLE CLERK

(Continue on separate sheet if necessary)

SIGNATURE DATE

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 / NATURE OF WORK
From To

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

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAININGPROGRAMS ATTENDED
INCLUSIVE DATES OF Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAININGPROGRAMS ATTENDANCE ( 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

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

(Continue on separate sheet if necessary)

SIGNATURE DATE
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 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?
38. a. Have you ever been a candidate in a national or local election held within the last year (except Barangay
YES NO
election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last election to YES NO
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

c.
Are you a solo parent? If YES, please specify ID No:
YES NO

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAME ADDRESS TEL. NO. Computer generated or

phoocopied picture is
MARIAN BERMUDEZ QUEZON CITY 89277215 not acceptable

ANNIE G. CAPULLA PROJECT 8 QUEZON CITY 9189346003

PHOTO

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.

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

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

ID/License/Passport No.: 33-124176-8

Signature (Sign inside the box)
OCTOBER 4, 2023
Date/Place of Issuance: QUEZON CITY
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.

CHRISTOPHER V. MONDALA
Principal II
Person Administering Oath

CS FORM 212 (Revised 2017), Page 4 of 4