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 DELA CRUZ
NAME EXTENSION (JR., SR)
FIRST NAME JUAN

MIDDLE NAME PALABAN JR.

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 10/2/1981 ✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH QUEZON CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female
✘ Single Married 17. RESIDENTIAL ADDRESS 123 Visayas Avenue
6 CIVIL STATUS
Widowe Separated House/Block/Lot No. Street
d N/A Vasra
Other/s: Subdivision/Village Barangay
Quezon City National Capital Region
7. HEIGHT (m) 1.68
City/Municipality Province
8. WEIGHT (kg) 60 ZIP CODE 1101

18. PERMANENT ADDRESS 123 Visayas Avenue

9. BLOOD TYPE O
House/Block/Lot No. Street
N/A Vasra
10. GSIS ID NO. 2002-234111
Subdivision/Village Barangay
Quezon City National Capital Region
11. PAG-IBIG ID NO. 123456
City/Municipality Province

12. PHILHEALTH NO. 123456 ZIP CODE 1101

13. SSS NO. 123456 19. TELEPHONE NO. 1234567

14. TIN NO. 123456 20. MOBILE NO. 12345678910

15. AGENCY EMPLOYEE NO. 123 21. E-MAIL ADDRESS (if any) juan@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 N/A

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME DELA CRUZ

NAME EXTENSION (JR., SR)
FIRST NAME JUAN

MIDDLE NAME MATIPUNO N/A

25. MOTHER'S MAIDEN NAME

SURNAME PALABAN

FIRST NAME JUANA

MIDDLE NAME KATIPUNAN (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 PUROK NAGKAISA NATIONAL HIGH SCHOOL ELEMENTARY 5/6/1989 3/4/1995 N/A 1992 N/A

SECONDARY /
VOCATIONAL PUROK NAGKAISA NATIONAL HIGH SCHOOL HIGH SCHOOL 11/6/1995 11/4/1999 N/A 1996 N/A

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

TRADE
COURSE
COLLEGE SAN ISIDRO COLLEGE BS Criminology 6/26/1999 4/27/2000 23 units 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
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

Career Service Sub-professional 80.1 1/17/2002 Quezon City N/A N/A

Non-professional Driver's License N/A 1/2/2017 Quezon City NO2-1234567 1/2/2022

N O T H I N G F O L L O W S

(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)

4/22/2015 PRESENT Clerk KRC Innovations 13,000 PHP N/A Regular N

5/1/2010 1/4/2015 Custodian EdMark Solutions Inc. 12,000 PHP N/A Regular N

1/12/2000 12/31/2009 Service Crew Mcdonald's 9,000 PHP N/A Regular N

N O T H I N G F O L L O W S

(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
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 in
(Write in full)
full)

Driving N/A N/A

- NOTHING FOLLOWS -

(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 ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? YES
If YES, give details:
________________________________
N/A

35. a. Have you ever been found guilty of any administrative offense? YES ✘ NO
If YES, give details:
________________________________
N/A
________________________________
b. Have you been criminally charged before any court? YES ✘ NO
If YES, give details:
________________________________
Date Filed: N/A
________________________________
Status of Case/s: N/A

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:
________________________________
N/A
________________________________
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? ________________________________
RESIGNATION
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except YES ✘ NO
Barangay election)? N/A
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: N/A
39. Have you acquired the status of an immigrant or permanent resident of another country?
YES ✘ NO
If YES, give details (country):
N/A
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: N/A
b. Are you a person with disability? YES ✘ NO
If YES, please specify ID No: N/A
c. Are you a solo parent? YES ✘ NO
If YES, please specify ID No: N/A

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

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
PEDRO R. SANTOS McDonald's, Visayas Avenue 2234456 4.5 cm. X 3.5 cm
(passport size)

REYNALDO O. PULIDO EdMark Solutions Inc., Quezon City 3456789

Computer generated
or photocopied picture
SUSAN E. JOSE KRC Innovations, Recto, Manila 1234444 is not acceptable

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 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: Driver's License

ID/License/Passport No.: NO2-1234567

Signature (Sign inside the box)

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.

Person Administering Oath

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