csform no. 212 personal data sheet

Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE. 1. CS ID No.

2.

3.16. CITIZENSHIP

4. PLACE OF BIRTH

5. SEX

17. RESIDENTIAL ADDRESS

8.

18. PERMANENT ADDRESS

12. PHILHEALTH NO.

13. SSS NO. 19. TELEPHONE NO.

20. MOBILE NO.

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

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME

FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME

FIRST NAME

MIDDLE NAME

25. MOTHER'S MAIDEN NAME

SURNAME

FIRST NAME

MIDDLE NAME

III. EDUCATIONAL BACKGROUND

From To

ELEMENTARY

SECONDARY

VOCATIONAL /

TRADE COURSE

COLLEGE

GRADUATE STUDIES

CS FORM 212 (Revised 2017),

SIGNATURE

(Continue on separate sheet if necessary)

DATE

HIGHEST LEVEL/ UNITS EARNED (if not graduated)

NAME EXTENSION (JR., SR)

BASIC EDUCATION/DEGREE/COURSE

(Write in full)

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.

LEVELNAME OF SCHOOL

(Write in full)

Barangay

ProvinceCity/Municipality

City/Municipality Province

ZIP CODE

PERSONAL DATA SHEET

I. PERSONAL INFORMATION

(Do not fill up. For CSC use only)

SCHOLARSHIP/

ACADEMIC

HONORS

RECEIVED

DATE OF BIRTH (mm/dd/yyyy)

26. YEAR GRADUATED

SURNAME

FIRST NAME

MIDDLE NAME

ZIP CODE


14. TIN NO.

23. NAME of CHILDREN (Write full name and list all)

9.

HEIGHT (m)

WEIGHT (kg)

BLOOD TYPE

GSIS ID NO.

PAG-IBIG ID NO.


please indicate the details.

If holder of dual citizenship, Pls. indicate country:

House/Block/Lot No. Street

Subdivision/Village Barangay

House/Block/Lot No.

READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.

Street

Subdivision/Village

10.

11.

6

7.

CIVIL STATUS

DATE OF BIRTH

(mm/dd/yyyy)


PERIOD OF ATTENDANCE

CS Form No. 212Revised 2017

Filipino Dual Citizenship

Male Female

Single Married

Widowed

Other/s:

Separated

by birth by naturalization

PUP : 04/07/2022 12:13:13 AM

PEÑAFLORIDA

JHUNEL N/A

BUENAVENTURA

08/18/1997

FA0003UQ2019

UNISAN, QUEZON

/

N/A/

1.65

55

AB+

/

121225488803

080264584128

748-776-456-000

N/A

09463205717

[email protected]

4305

4305

09463205717

PEÑAFLORIDA

ANTONIO N/A

EBIA

BUENAVENTURA

EDNA

CALIBO

N/A

N/A N/A

N/A

N/A

N/A

N/A

N/A

N/A N/A

ALMACEN UNISAN, QUEZON

ALMACEN UNISAN, QUEZON

ALMACEN ELEMENTARYSCHOOL

PRIMARY EDUCATION2003 2009 2009N/A

SALUTATORIAN

LEONARDA D. VERA CRUZNATIONAL HIGH SCHOOL

HIGH SCHOOL 2009 2013 2013N/AVALEDICTORIAN

POLYTECHNIC UNIVERSITY OF THE PHILIPPINESUNISAN, QUEZON BRANCH BACHELOR OF SCIENCE IN

INFORMATION TECHNOLOGY2014 2018 2018N/A ACADEMIC

DISTINCTION

POLYTECHNIC UNIVERSITY OF THE PHILIPPINECOMMONWEALTH BRANCH MASTER IN INFORMATION

TECHNOLOGY2018 2022 N/A33 N/A

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

of 6

27.

NUMBERDate of

Validity

(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experience sheet.

28.

To

DATE


CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER

SPECIAL LAWS/ CES/ CSEE

BARANGAY ELIGIBILITY / DRIVER'S LICENSE

DATE OF

EXAMINATION /

CONFERMENT

PLACE OF EXAMINATION / CONFERMENT

LICENSE (if applicable)RATING

(If Applicable)

IV. CIVIL SERVICE ELIGIBILITY

GOV'T

SERVICE

(Y/ N)

SALARY/ JOB/ PAY

GRADE (if

applicable)& STEP

(Format "00-0")/

INCREMENTFrom

POSITION TITLE

(Write in full/Do not abbreviate)

DEPARTMENT / AGENCY / OFFICE / COMPANY

(Write in full/Do not abbreviate)

MONTHLY

SALARY

INCLUSIVE DATES

(mm/dd/yyyy)


V. WORK EXPERIENCE

STATUS OF

APPOINTMENT

SIGNATURE


PUP : 04/07/2022 12:13:13 AM

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

06/17/2019 PRESENT PART-TIME INSTRUCTOR I POLYTECHNIC UNIVERSITY OF THEPHILIPPINES

18,690 0-0 PART-TIME Y

of 6

From To

From To

31. SPECIAL SKILLS and HOBBIES 32. 33.


DATE


NON-ACADEMIC DISTINCTIONS / RECOGNITION

(Write in full)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION

(Write in full)

NUMBER OF HOURS

SIGNATURE

VIII. OTHER INFORMATION

TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS

(Write in full)

(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)

Type of LD

( Managerial/

Supervisory/

Technical/etc)

29. NAME & ADDRESS OF ORGANIZATION

(Write in full)


POSITION / NATURE OF WORK

INCLUSIVE DATES

(mm/dd/yyyy)

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

CONDUCTED/ SPONSORED BY

(Write in full)

INCLUSIVE DATES OF

ATTENDANCE

(mm/dd/yyyy)


VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED

NUMBER OF HOURS30.

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COMPUTER AND HARWARETROUBLESHOOTINGCOMPUTER ARTS AND DESIGN

COMPUTER PROFICIENCY

EXCELLENT ORAL AND WRITTENCOMMUNICATIONPROGRAMMING PROFICIENCY

WEB DESIGN AND DEVELOPMENT

PHILIPPINE SCHOOLS, UNIVERSITIES AND COLLEGESCOMPUTER EDUCATION AND SYSTEMS SOCIETY, INCN/A

of 6

a.

If YES, please specify:

b.

If YES, please specify ID No:

c.

If YES, please specify ID No:

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

ADDRESS

Date Filed:

Status of Case/s:

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

PLEASE INDICATE ID Number and Date of Issuance

Signature (Sign inside the box)

39.

41.

If YES, give details (country):

b. Have you been criminally charged before any court?

If YES, give details:


________________________________


Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation

by any court or tribunal?


Person Administering Oath

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

Right ThumbmarkDate AccomplishedDate/Place of Issuance:

Government Issued ID:

ID/License/Passport No.:

a. Have you ever been a candidate in a national or local election held within the last year (except

Barangay election)?

37.

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?

38.



36.

PHOTO

NAME TEL. NO.

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.

34.


chief of bureau or office or to the person who has immediate supervision over you in the Office,

a. within the third degree?

b. within the fourth degree (for Local Government Unit - Career Employees)?

Are you related by consanguinity or affinity to the appointing or recommending authority, or to the

Bureau or Department where you will be apppointed,

Are you a person with disability?

Are you a solo parent?

40.

Have you acquired the status of an immigrant or permanent resident of another country?

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?

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 phased

out (abolition) in the public or private sector?

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


ID picture taken within the last 6 months3.5 cm. X 4.5 cm(passport size)

With full and handwrittenname tag and signature over

printed name

Computer generated or photocopied picture

is not acceptable

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES

YES

YES

NO

NO

NO

YES NO

YES NO

PUP : 04/07/2022 12:13:13 AM

BAMBA, LENY SALOMON LUCENA CITY 09399076426

ESCOBAR, CORAZON VALENZUELA UNISAN,QUEZON 09392040626

MALABUYOC, EDWIN GUEVARRA STO. TOMAS, BATANGAS 09985774016

/

/

N/A

/

N/A

/

N/A

N/A

/

N/A

/

N/A

/

N/A

/N/A

/

N/A

/N/A

/

N/A/

N/A

PUP ID

FA0003UQ2019

PUP MAIN

of 6

From To




(Write in full)

Type of LD

( Managerial/

Supervisory/

Technical/etc)

INCLUSIVE DATES OF

ATTENDANCE

(mm/dd/yyyy)TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS

(Write in full)



NUMBER OF HOURS30.

DATESIGNATURE

PUP : 04/07/2022 12:13:13 AM

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UNDERSTANDING WIRELESS EVOLUTION:2G, 3G, 4G LTEAND 5G NETWORKS

06/19/2021 06/19/2021 2 Technical DICT - LUZON CLUSTER 3CAMARINES SUR

VISUAL BASIC.NET TOOLS FOR DATA VISUALIZATION 06/11/2021 06/11/2021 2 Technical DICT LUZON CLUSTER 3 -CAMARINES NORTE

IMPACT OF ONLINE DELIVERY MODE OF LEARNING ONACADEMIC AND PSYCHOLOGICAL ASPECTS

05/28/2021 05/28/2021 5 ManagerialOVPSAS OFFICE OF COUNSELING ANDPSYCHOLOGICAL SERVICES

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of 6

From To




(Write in full)

Type of LD

( Managerial/

Supervisory/

Technical/etc)

INCLUSIVE DATES OF

ATTENDANCE

(mm/dd/yyyy)TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS

(Write in full)



NUMBER OF HOURS30.

DATESIGNATURE

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of 6

csform no. 212 personal data sheet

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