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 ITANG
FIRST NAME PAUL JAKE NAME EXTENSION (JR., SR) N/A
MIDDLE NAME BARRIENTOS
3. DATE OF BIRTH
12/8/1986 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH DAANBANTAYAN, CEBU If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male ✘ Female
17. RESIDENTIAL ADDRESS SUBA PROPER
6 CIVIL STATUS ✘ Single Married
House/Block/Lot No. Street
Widowed Separated
TALISAY
Other/s:
Subdivision/Village Barangay
DAANBANTAYAN CEBU
7. HEIGHT (m) 1.75
City/Municipality Province
8. WEIGHT (kg) 70 KGS. ZIP CODE 6013
18. PERMANENT ADDRESS SUBA PROPER
9. BLOOD TYPE 0+
House/Block/Lot No. Street
TALISAY
10. GSIS ID NO. N/A
Subdivision/Village Barangay
DAANBANTAYAN CEBU
11. PAG-IBIG ID NO. 121267348922
City/Municipality Province
12. PHILHEALTH NO. 12-050640602-7 ZIP CODE 6013
13. SSS NO. 0627432103 19. TELEPHONE NO. N/A
14. TIN NO. 349201649 20. MOBILE NO. 09978747615 - 09934662258
15. AGENCY EMPLOYEE NO. PJBI-228-134 21. E-MAIL ADDRESS (if any) pauljakeitang05@[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) 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 ITANG
FIRST NAME CARLITO SR
MIDDLE NAME PATALITA
25. MOTHER'S MAIDEN NAME
SURNAME BARRIENTOS
FIRST NAME FE
MIDDLE NAME CATAYOC (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 TALISAY ELEMENTARY SCHOOL ELEMENTARY 1999 2000 COMPLETED 2000 N/A
SECONDARY /
VOCATIONAL TOMINJAO NATIONAL HIGH SCHOOL HIGH SCHOOL 2000 2004 COMPLETED 2004 N/A
HIGH-SKILL TECHNICAL TRAINING CENTER
INC.
COMPUTER SCIENCE BASIC 2018 2019 NC11 2019 N/A
TRADE
BACHELOR OF SCIENCE IN MECHANICAL
COURSE
COLLEGE UNIVERSITY CEBU
ENGINEERING (BSME)
2005 2010 COMPLETED 2010 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 January 9, 2024
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
N/A N/A N/A N/A 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) STATUS OF
(Write in full/Do not (Write in MONTHLY SALARY applicable)& STEP
APPOINTMENT
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)
8/1/2022 PRESENT LGU-DAANBANTAYAN 6500.00 N/A YES
PUROK ORGANIZER / EVALUATOR JOB ORDER
2/1/2020 2/1/2022 INCODER, PURCHASER,CANVASER,
WHAREHOUSE INCHARGE VICENTE TE LAO CONTRUCTION 12000.00 N/A NO
6/16/2019 1/25/2020
HAWKER CASHIER SM SEASIDE CINEMA N/A NO
10000.00
3/2/2015 2/15/2017
TOURIST GUIDE ROYAL DIVE CENTER 10000.00 N/A NO
9/5/2010 10/20/2014 FINISHING CARPENTER W-GROUP CONTRUCTION MALAYSIA 20000.00
N/A NO
7/1.2008 3/30/2009 SALES MAN SAN BRUNO LUMBER 7000.00
N/A NO
FEEDER APPAREL CORPORATION /
8/1/2007 5/20/2008 WORKING STUDENT / UTILITY 6000.00
N/A NO
MEPZA 2
REBISCO MERCHANDISER / WORKING
2/1/2007 9/1/2007 WHITE GOLD CLUB 6000.00
N/A NO
STUDENT
MONDE NISSEN MERCHANDISER /
9/5/2006 8/10/2007 WHITE GOLD CLUB 6000.00
N/A NO
WORKING STUDENT
5/1/2002 2/1/2004 SALES MAN / WORKING STUDENT WHITE GOLD CLUB 5000.00
N/A NO
(Continue on separate sheet if necessary)
SIGNATURE DATE
09/01/2024
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
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
NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32.
(Write in full) (Write in full)
N/A
READING BOOKS
CHAIRMAN OF ALPHA KAPPA RHO DAANBANTAYAN COUNCIL
LISTENING MUSIC AND DANCING
WRITING LETTERS, POEMS AND SHORT VICE CHAIRMAN OF ( DUFO ) DAANBANTAYAN
STORIES UNITED FRATERNITY ORGANIZATION
CHAIRMAN OF ALPHA KAPPA RHO 4TH DISTRICT
ORGANIZING STUFFS AND FILING PAPERS
COUNCIL
DRAWING AND LITTERING
TATTOO ARTIST
(Continue on separate sheet if necessary)
SIGNATURE DATE
09/01/2024
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 ✘ NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘ NO
If YES, give details:
________________________________
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 Case/s:
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:
________________________________
________________________________
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
BAKYARD POBLACION, the last 6 months
9057388805
VICENTE A. LOOT DAANBANTAYAN,CEBU 3.5 cm. X 4.5 cm
(passport size)
POBLACION DAANBANTAYAN 9064868834
JUPJUP ROSELL With full and handwritten
name tag and signature over
printed name
LOGON, DAANBANTAYAN,CEBU 9177266806
REX M. NOVABOS Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or 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 filing of PHOTO
administrative/criminal case/s against me.
Government Issued ID: DRIVER LICENSE
ID/License/Passport No.: N02-10-410031 Signature (Sign inside the box)
01/09/2024
Date/Place of Issuance:
12/08/2021, LAPU LAPU CEBU Date Accomplished Right Thumbmark
SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.
SUN J. SHIMURA
MUNICIPAL MAYOR
CS FORM 212 (Revised 2017), Page 4 of 4
