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

MIDDLE NAME CALUCIN Widow/er

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 4/3/1994 ✘ Filipino Dual Citizenship
✘
by by
birth naturalization
4. PLACE OF BIRTH MAUBAN, QUEZON If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female Others

6 CIVIL STATUS ✘ Single 17. RESIDENTIAL ADDRESS

Married
Widowe Separat House/Block/Lot No. Street
SAN LORENZO
d ed
Other/s: Subdivision/Village Barangay
7. HEIGHT (m) 1.98
MAUBAN QUEZON
City/Municipality Province
8. WEIGHT (kg) 75 ZIP CODE

18. PERMANENT ADDRESS

9. BLOOD TYPE AB
House/Block/Lot No. Street
SAN LORENZO
10. GSIS ID NO. N/A
Subdivision/Village Barangay
MAUBAN QUEZON
11. PAG-IBIG ID NO. 121290833025
City/Municipality Province

12. PHILHEALTH NO. 082524664387 ZIP CODE 4330

13. SSS NO. 35 - 0851662 - 4 19. TELEPHONE NO. N/A

14. TIN NO. 509 - 956 - 641 - 00000 20. MOBILE NO. 09989275126 / 09815326545

15. AGENCY EMPLOYEE NO.
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME
FIRST NAME
N/A 21. E-MAIL ADDRESS (if any) dolancalucin@gmail.com
Bosnia and Herzegovina
23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
N/A N/A

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME AURINO

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

MIDDLE NAME CABILLO

25. MOTHER'S MAIDEN NAME

SURNAME CALUCIN

FIRST NAME TEODORA

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

ELEMENTARY MOTHER PERPETUA PAROCHIAL SCHOOL N/A 2001 2007 N/A 2007 N/A

SECONDARY /
VOCATIONAL MOTHER PERPETUA PAROCHIAL SCHOOL N/A 2007 2011 N/A 2011 N/A

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

TRADE
COURSE
COLLEGE SOUTHERN LUZON STATE UNIVERSITY BACHELOR OF SCIENCE IN CIVIL ENGINEERING 2011 2013 N/A N/A N/A

BACHELOR OF SCIENCE IN INDUSTRIAL

COLLEGE SOUTHERN LUZON STATE UNIVERSITY 2013 2019 N/A N/A N/A
ENGINEERING

BACHELOR OF SCIENCE IN INDUSTRIAL

COLLEGE SOUTHERN LUZON STATE UNIVERSITY 2019 2020 N/A 2020 N/A
ENGINEERING

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

(Continue on separate sheet if necessary)

SIGNATURE DATE June 28, 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

CSC - PPT (PROFESSIONAL) PASSED 3/26/2023 DALAHICAN NATIONAL HIGH SCHOOL, LUCENA CITY 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
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)
LOCAL GOVERNMENT UNIT MAUBAN (TOURISM CONTRACT OF
11/09/21 06/31/22 TECHNICAL STAFF (TOURISM OPERATION SECTION) 8,000.00 N/A YES
OFFICE) SERVICE

CONTRACT OF
01/19/23 06/30/23 OFFICE CLERK (MPDC - ZONING) LOCAL GOVERNMENT UNIT MAUBAN (MPDC) 10,000.00 N/A YES
SERVICE

(Continue on separate sheet if necessary)

SIGNATURE DATE June 28, 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
(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

FIRST AIDE TRAINING (CPR) 11/09/2021 11/10/2021 8 N/A LOCAL GOVERNMENT UNIT OF MAUBAN QUEZON

LEAN SIX SIGMA WHITEBELT 07/04/2021 07/04/2021 4 N/A SIX SIGMA PH

40 HOURS CONSTRUCTION OCCUPATIONAL SAFETY AND HEALTH TRAINING WITH 2 HOURS

09/26/2020 10/04/2020 40 N/A JGT SAFETY TRAINING CENTER
TRAINING OF TRAINER

INNOVATING QUALITY INDUSTRIAL ENGINEERS TO LEVEL UP THE NEW GENERATIONS 04/21/2017 04/21/2017 8 N/A SOUTHERN LUZON STATE UNIVERSITY

APPRAISING THE ALTERNATIVES FOR EFFECTIVE BREAKTHROUGH 10/03/2015 10/03/2015 8 N/A UPLB, LOS BAÑOS, LAGUNA

(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)

FAST LEARNER LEAGUE OF INDUSTRIAL ENGINEERS SOCIETY

GOOD INTERPERSONAL SKILLS OPERATIONAL RESEARCH SOCIETY OF THE PHILIPPINES

MICROSOFT OFFICE APPLICATIONS LITERATE FUTURE ENGINEERS LEAGUE

DEDICATED, DETERMINED AND HARD WORKER

(Continue on separate sheet if necessary)

SIGNATURE DATE June 28, 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? YE ✘ NO
b. within the fourth degree (for Local Government Unit - Career Employees)? S
YE ✘ NO
If YES, give details:
S ________________________________
________________________________

a. Have you ever been found guilty of any administrative offense?

35.
YE ✘ NO
S ________________________________
If YES, give details:
________________________________

b. Have you been criminally charged before any court?

YE ✘ NO
S ________________________________
If YES, give details:
________________________________
Date Filed:
Status of Case/s:
Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation
36. by any court or tribunal?
YE ✘ NO
S ________________________________
If YES, give details:
________________________________

Have you ever been separated from the service in any of the following modes: resignation,
37.
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased YE ✘ NO
out (abolition) in the public or private sector? S ________________________________
If YES, give details:
________________________________

a. Have you ever been a candidate in a national or local election held within the last year (except
38. Barangay election)? YE ✘ NO
IfSYES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last
YE ✘ NO
election to promote/actively campaign for a national or local candidate? If YES, give details:
S
Have you acquired the status of an immigrant or permanent resident of another country?
39.
YE ✘ NO
S (country):
If YES, give details

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?

YE ✘ NO
S
If YES, please specify:
b. Are you a person with disability?
YE ✘ NO
S ID No:
If YES, please specify

c. Are you a solo parent?

YE ✘ NO
If YES, please specify
S ID No:

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

NAME ADDRESS TEL. NO.

ID picture taken within
PEÑALOSA ST, BRGY. BAGONG BAYAN, the last 6 months
ROBERTO DEL RIO 9477592030 3.5 cm. X 4.5 cm
MAUBAN, QUEZON
(passport size)

COL. ARIEL QUIRUBIN PN (M) RETIRED SAN MIGUEL CORPORATION 9175414289 With full and handwritten
name tag and signature over
printed name
MIGUELITO D. CAMELON BRGY. MACASIN, MAUBAN, QUEZON 9462835462
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete or photocopied picture
is not acceptable
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 PHOTO
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.: 35 - 0851662 - 4

Signature (Sign inside the box)
Date/Place of Issuance: June 28, 2023
JULY 27, 2021 / LUCENA CITY
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this June 28, 2023 , affiant exhibiting his/her validly issued government ID as indicated above.

Conchita Marta F. Mirabueno

MGHD - 1 HRMO

Person Administering Oath

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