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 DIAZ
NAME EXTENSION (JR., SR)
FIRST NAME ARLON JOHN N/A
MIDDLE NAME MARIÑAS
3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) Filipino Dual Citizenship
03/26/1996 by birth by naturalization
4. PLACE OF BIRTH
TONDO, MANILA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female
6 CIVIL STATUS
Single Married 17. RESIDENTIAL ADDRESS N/A N/A
House/Block/Lot No. Street
Widowed Separated
Other/s:
N/A N/A
Subdivision/Village Barangay
N/A N/A
7. HEIGHT (m)
1.64 City/Municipality Province
8. WEIGHT (kg) 50 ZIP CODE N/A
225 PUROK 6
O
9. BLOOD TYPE 18. PERMANENT ADDRESS
House/Block/Lot No. Street
N/A TICOL
10. GSIS ID NO.
N/A Subdivision/Village Barangay
SORSOGON CITY SORSOGON
11. PAG-IBIG ID NO. 1212-4361-1396 City/Municipality Province
12. PHILHEALTH NO. 10-202901759-7 ZIP CODE 4700
13. SSS NO. 05-1497281-5 19. TELEPHONE NO. N/A
14. TIN NO. 755-473-828 20. MOBILE NO. 0945-807-5874
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) arlonjohn26@[Link]
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 N/A N/A
MIDDLE NAME N/A N/A N/A
OCCUPATION N/A N/A N/A
EMPLOYER/BUSINESS NAME N/A N/A N/A
BUSINESS ADDRESS N/A N/A N/A
TELEPHONE NO. N/A N/A N/A
24. FATHER'S SURNAME DIAZ N/A N/A
NAME EXTENSION (JR., SR)
FIRST NAME ROLAND N/A N/A N/A
MIDDLE NAME JAYCO N/A N/A
25. MOTHER'S MAIDEN NAME AMELIA OCA MARIÑAS N/A N/A
SURNAME MARIÑAS N/A N/A
FIRST NAME AMELIA N/A N/A
MIDDLE NAME OCA (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
SCHOLARSHIP/
26. PERIOD OF ATTENDANCE HIGHEST LEVEL/
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE YEAR ACADEMIC
LEVEL UNITS EARNED
(Write in full) (Write in full) GRADUATED HONORS
(if not graduated)
From To RECEIVED
ELEMENTARY ROSAURO ALMARIO ELEMENTARY SCHOOL
SECONDARY
VOCATIONAL /
TRADE COURSE
COLLEGE
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
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE / of
CONFERMENT Validity
(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
PAY GRADE (if GOV'T
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / MONTHLY STATUS OF
applicable)& STEP SERVIC
(Write in full/Do not abbreviate) COMPANY SALARY APPOINTMENT
(Format "00-0")/ E (Y/ N)
From To (Write in full/Do not abbreviate) INCREMENT
(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
(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 Type of
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS OF ATTENDANCE LD ( CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Managerial/ (Write in full)
Supervisory/
From To Technical/etc)
(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,
[Link] the third degree? YES N
[Link] the fourth degree (for Local Government Unit - Career Employees)? YES O
If YES, give details: N
O
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
Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation Case/s:
36.
YES NO
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, 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?
38. a. Have you ever been a candidate in a national or local election held within the last year (except YES NO
Barangay election)? 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:
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
If YES, please specify ID No:
c.
Are you a solo parent? YES NO
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
(passport size)
With full and handwritten name
tag and signature over printed
name
Computer generated or
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and photocopied picture is
not acceptable
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 PHOTO
filing of administrative/criminal case/s against me.
Government Issued ID ([Link], GSIS, SSS, PRC, Driver's License, etc.)
PLEASE INDICATE ID Number and Date of Issuance
Government Issued ID:
ID/License/Passport No.: Signature (Sign inside the box)
Date/Place of Issuance:
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
