CS Form No.

212

PERSONAL DATA SHEET

Revised 2017

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. D1. CS ID N (Do not fill [Link] CSCuse only)
I. PERSONAL INFORMATION
2. SURNAME ANTIPASADO
JR.
FIRST NAME ROLANDO

MIDDLE NAME LIAGOSO

3. DATE OF BIRTH

(mm/dd/yyyy) 11/14/1999 16. CITIZENSHIP

4. PLACE OF BIRTH PANABO CITY If holder of dual citizenship, Pls. indicate country:

5. SEX
please indicate the details.


17. RESIDENTIAL ADDRES
6 CIVIL STATUS
House/Block/Lot No. Street
Joesil Village 3 Cagangohan
Subdivision/Village Barangay
7. HEIGHT (m) 1.63m Panabo Davao Del Norte
City/Municipality Province
8. WEIGHT (kg) 52 ZIP CODE 8105

18. PERMANENT ADDRES

9. BLOOD TYPE 'O''
House/Block/Lot No. Street
Joesil Village 3 Cagangohan
10. GSIS ID NO. NA
Subdivision/Village Barangay
Panabo City Davao Del Norte
11. PAG-IBIG ID NO. NA
City/Municipality Province

2. PHILHEALTH NO. 16-252783657-3 ZIP CODE 8105

3. SSS NO. NA 19. TELEPHONE NO.

14. TIN NO. NA 20. MOBILE NO. 09934205473

15. AGENCY EMPLOYEE NO. NA 21. E-MAIL ADDRESS (if ancatcher111499@[Link]

II. FAMILY BACKGROUND

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

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAM

BUSINESS ADDRESS

TELEPHONE NO.

[Link]'S SURNAME ANTIPASADO

SR.
FIRST NAME ROLANDO

MIDDLE NAME APAS

25 MOTHER'S MAIDEN NAME

SURNAME

FIRST NAME DECEASED

MIDDLE NAME (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

PERIOD OF SCHOLARSHIP/
26. HIGHESTLEVEL/
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE ATTENDANCE YEAR ACADEMIC
LEVEL UNITSEARNED
(Write in full) (Write in full) GRADUATED HONORS
(if not graduated)
From To RECEIVED

ELEMENTARY LA LIBERTAD ELEMENTARY SCHOOL ELEMENTARY GRADUATE 2007 2013 2013

SECONDARY A.O.F NATIONAL HIGH SCHOOL HIGH SCHOOL GRADUATE 2013 2019 2019

VOCATIONAL /
TRADE COURSE

COLLEGE

BACHELOR OF SCIENCE IN UNDERGR

GRADUATE STUDIES ACES POLYTECHNIC COLLEGE INC. 2022 2024
CRIMINOLOGY AD
(Continue on separate sheet if necessary)

SIGNATURE DATE MAY 16,2023

CSFORM212 (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

NA

(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 applicable)& STATUS OF GOV'T SERVICE
(Write in full/Do not abbreviate) (Write in full/Do not abbreviate) SALARY STEP (Format "00 APPOINTMENT (Y/ N)
-0")/ INCREMENT
From To

NA

(Continue on separate sheet if necessary)

SIGNATURE DATE MAY 16,2023

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

NA

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
INCLUSIVE DATES OF Type of LD

30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/
(Write in full)
Technical/etc)
From To
YOUTH VOLUNTEER ORIENTATION COURSE, LEADERSHIP FORMATION Philippine Red Cross (Red Cross Youth
12/6/2022 12/7/2022 16h
COURSE AND BASIC TRAINING Department)

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

COMPUTER LITERATE MICROSOFT OFFICE

(Continue on separate sheet if necessary)

SIGNATURE DATE MAY 16,2023

CS FORM 212 (Revised 2017), Page 3 of 4
34. Are you related by consanguinity or affinity to the appointing or recommending
chief of bureau or office or to the person who has immediate supervision over
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:
tatus 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 If YES, give details:
term, finished contract or 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 If YES, give details:
local candidate?
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)
a. please
Are you aanswer
member theoffollowing items: group?
any indigenous
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)

ID picture taken within

NAME ADDRESS TEL. NO. the last 6 months

4.5 cm. X 3.5 cm

HON. RUSSEL S. DUMAGIL PANABO CITY (passport size)

Computer generated

HON. ALMA FUENTES PANABO CITY or photocopied picture

is not acceptable

HON. JULIUS E. DUJALI PANABO CITY

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 PHOTO
misrepresentation made in this document and its attachments shall cause the 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

Yes/No Cstat Gender
Yes Single Male
No Married Female
Separated
Widowed