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 BALBADA

FIRST NAME JULY-ANN NAME EXTENSION (JR., SR) N/A

MIDDLE NAME RELLORTA

3. DATE OF BIRTH
(mm/dd/yyyy) 09/20/1999 16. CITIZENSHIP FILIPINO

4. PLACE OF BIRTH CSJDM, BULACAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX FEMALE NA

6 CIVIL STATUS SINGLE

17. RESIDENTIAL ADDRESS BLOCK 220 LOT4 PUROK 10
House/Block/Lot No. Street
STA.CRUZ V
Subdivision/Village Barangay
7. HEIGHT (m) 4'11 SAN JOSE DEL MONTE BULACAN
City/Municipality Province
8. WEIGHT (kg) 48 ZIP CODE 3023

9. BLOOD TYPE NA
18. PERMANENT ADDRESS BLOCK 220 LOT4 PUROK 10
House/Block/Lot No. Street
10. GSIS ID NO. NA STA.CRUZ V
Subdivision/Village Barangay
SAN JOSE DEL MONTE BULACAN
11. PAG-IBIG ID NO. NA
City/Municipality Province

12. PHILHEALTH NO. 21-025862411-9 ZIP CODE 3023

13. SSS NO. 35-1371374-2 19. TELEPHONE NO. NA

14. TIN NO. NA 20. MOBILE NO. 09656857344

15. AGENCY EMPLOYEE NO. NA 21. E-MAIL ADDRESS (if any) [email protected]

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME BALBADA

JR
FIRST NAME JOSE

MIDDLE NAME ROSALES

25. MOTHER'S MAIDEN NAME

SURNAME GERALDINO

FIRST NAME MARCELINA

MIDDLE NAME RELLORTA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

26. NAME OF SCHOOL

PERIOD OF ATTENDANCE HIGHEST LEVEL/
BASIC EDUCATION/DEGREE/COURSE UNITS YEAR SCHOLARSHIP/ ACADEMIC
LEVEL (Write in EARNED GRADUATED HONORS RECEIVED
(Write in full)
full) (if not graduated)
From To

SAN RAFAEL (BBH)ELEMENTARY

ELEMENTARY GRADE I - GRADE VI 2006 2012 NA 2012 NA
SCHOOL

SECONDARY
VOCATIONAL / FVR NATIONAL HIGHSCHOOOL FIRST YEAR - FOURTH YEAR 2012 2016 NA 2016 NA

LUIS GRAVADOR SENIOR HIGHSCHOOL GRADE 11- GRADE 12 2016 2018 NA 2018 NA

TRADE
COURSE BULACAN STATE UNIVERSITY- BACHELOR OF SECONDARY
COLLEGE 2018 2022 NA 2022 NA
SARMIENTO CAMPUS EDUCATION

GRADUATE STUDIES NA NA NA NA NA NA NA

(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL , 2024

IV. CIVIL SERVICE ELIGIBILITY
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
DATE OF LICENSE (if applicable)
27. UNDER SPECIAL LAWS/ CES/ CSEE RATING Date of
EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY (If Applicable) NUMBER Validity
CONFERMENT
/ DRIVER'S LICENSE

(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 GOV'T SERVICE
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/ (Y/
(Write in full/Do not abbreviate) full/Do not abbreviate) INCREMENT
From To N)

(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

(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/
NUMBER OF HOURS
Supervisory/
CONDUCTED/ SPONSORED BY (Write in full)
(Write in full) (mm/dd/yyyy)
Technical/etc)
From To

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in full)

READING BOOKS

COMPUTER LITERATE

PHOTO EDITING

VIDEO EDITING

PHOTOGRAPHY

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 3 of 4
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 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?
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 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
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:
a. Are you a member of any indigenous group?
If YES, please specify:
b. Are you a person with disability?
If YES, please specify ID No:
c. 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
(passport size)

With full and handwritten

name tag and signature over
printed name

Computer generated
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.
or photocopied picture
is not acceptable

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:

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