CS Form No.
212
Revised 2017
PERSONAL DATA SHEET
WARNING: Any misinterpretation 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 COME
NAME EXTENSION (JR., SR) N/A
FIRST NAME YESSAMIN
MIDDLE NAME LEONA
3. DATE OF BIRTH
(mm/dd/yyyy) 16. CITIZENSHIP FILIPINO
11/8/2001
4. PLACE OF BIRTH BURAUEN, LEYTE If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX FEMALE N/A
17. RESIDENTIAL ADDRESS
6 CIVIL STATUS SINGLE
House/Block/Lot No. Street
N/A REAL NORTH
Subdivision/Village Barangay
7. HEIGHT (m) 1.52 LA PAZ LEYTE
City/Municipality Province
8. WEIGHT (kg) 50 ZIP CODE 6508
18. PERMANENT ADDRESS
9. BLOOD TYPE "O"
House/Block/Lot No. Street
10. GSIS ID NO. N/A N/A REAL NORTH
Subdivision/Village Barangay
11. PAG-IBIG ID NO. 121352638036 LA PAZ LEYTE
City/Municipality Province
12. PHILHEALTH NO. N/A ZIP CODE 6508
13. SSS NO. 06-4991233-9 19. TELEPHONE NO. N/A
14. TIN NO. N/A 20. MOBILE NO. 09267174409
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) yessangleona@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) N/A
FIRST NAME N/A N/A N/A
MIDDLE NAME N/A
OCCUPATION N/A
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME COME
NAME EXTENSION (JR., SR) N/A
FIRST NAME WILSON
MIDDLE NAME ABRAHAM
25. MOTHER'S MAIDEN NAME
SURNAME LEONA
FIRST NAME ROWENA
MIDDLE NAME BARDALO (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
HIGHEST LEVEL/
26. NAME OF SCHOOL PERIOD OF ATTENDANCE YEAR
LEVEL (Write in BASIC EDUCATION/DEGREE/COURSE
(Write in full)
UNITS
GRADUATED
SCHOLARSHIP/ ACADEMIC
HONORS RECEIVED
full) EARNED
(if not graduated)
From To
ELEMENTARY STA. ANA CENTRAL SCHOOL PRIMARY EDUCATION 2009 2014 GRADUATE 2014 WITH HONOR
SECONDARY STA. ANA NATIONAL HIGH SCHOOL HIGH SCHOOL 2015 2018 GRADUATE 2019 WITH HONOR
SENIOR HIGH SCHOOL 2019 2020
VOCATIONAL /
N/A N/A N/A N/A N/A N/A N/A
TRADE COURSE
COLLEGE LEYTE NORMAL UNIVERSITY BACHELOR OF TECHNOLOGY AND 2021 2024 GRADUATE 2024 CUM LAUDE
LIVELIHOOD EDUCATION
GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)
SIGNATURE DATE 10/28/2024 CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER RATING DATE OF
SPECIAL LAWS/ CES/ CSEE (If Applicable) EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT NUMBER Date of
Validity
PRESIDENTIAL DECREE NO. 907 N/A 07/17/24 CSC RO VIII 100108241072 07/17/24
(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 SALARY/ JOB/ PAY
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY GRADE (if STATUS OF GOV'T SERVICE
(Write in full/Do not SALARY
applicable)& STEP
APPOINTMENT (Y/N)
abbreviate) (Write in full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To
N/A N/A N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)
SIGNATURE DATE 10/28/2024 CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
NAME & ADDRESS OF ORGANIZATION POSITION / NATURE OF WORK
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS
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
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS ( Managerial/ Supervisory/ (Write
(Write in full) (mm/dd/yyyy) Technical/etc) in full)
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
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATI
SPECIAL SKILLS and HOBBIES (Write in full) 33. ON
(Write in full)
COMPUTER LITERATE N/A N/A
(Continue on separate sheet if necessary)
SIGNATURE DATE 10/28/2024
34. Are you related by consanguinity or affinity to the appointing or recommending authority, or
to theof bureau or office or to the person who has immediate supervision over you in the
chief
Office,
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, finished contract or If YES, give details:
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 the
following items:
Are you a member of any indigenous group?
If YES, please specify:
Are you a person with disability?
If YES, please specify ID No:
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 TEL. NO. ID picture taken within
the last 6 months
3.5 cm. X 4.5 cm
MRS. MARICEL B. ADONIS CABACUNGAN, DULAG, LEYE 9058971272 (passport size)
With full and handwritten
MRS. DERLY LLENADO STA. ANA LA PAZ, LEYTE 9498905927 name tag and signature over
printed name
MRS. PERLA COPINO STA. ANA LA PAZ, LEYTE 9753335218 Computer generated
or photocopied picture
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
administrative/criminal case/s against me. PHOTO
Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's
License, etc.) PLEASE INDICATE ID Number
and Date of Issuance
Government Issued ID: PHILSYYS
ID/License/Passport No.: 4369-2639-0620-1351 Signature (Sign inside the box)
Date/Place of Issuance: 10/07/2024 LA PAZ, LEYTE
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
