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 PICARDAL
NAME EXTENSION (JR., SR) N/A
FIRST NAME JOHN MARCK
MIDDLE NAME GRATA
3. DATE OF BIRTH
6/6/1993 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH ORAS, EASTERN SAMAR If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female
17. RESIDENTIAL ADDRESS N/A ZONE-01
6 CIVIL STATUS Single ✘ Married
House/Block/Lot No. Street
Widowed Separated
N/A CAMANGA
Other/s:
Subdivision/Village Barangay
ORAS EASTERN SAMAR
7. HEIGHT (m) 1.73
City/Municipality Province
8. WEIGHT (kg) 75 ZIP CODE 6818
18. PERMANENT ADDRESS N/A ZONE - 01
9. BLOOD TYPE O
House/Block/Lot No. Street
N/A CAMANGA
10. GSIS ID NO. N/A
Subdivision/Village Barangay
ORAS EASTERN SAMAR
11. PAG-IBIG ID NO. N/A
City/Municipality Province
12. PHILHEALTH NO. 13-025279265-2 ZIP CODE 6818
13. SSS NO. N/A 19. TELEPHONE NO. N/A

14. TIN NO. 725-111-591-000 20. MOBILE NO. 09760412564/09265601918

15. AGENCY EMPLOYEE NO. 2019-4004 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME PICARDAL 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

NAME EXTENSION (JR., SR)

FIRST NAME APRILYN N/A MARK JANSEN R. PICARDAL 04/20/2014

MIDDLE NAME REBATO KHALEX R. PICARDAL 02/17/2021

OCCUPATION BRGY. SECRETARY

EMPLOYER/BUSINESS NAME LGU BARANGAY CAMANGA
BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME PICARDAL

NAME EXTENSION (JR., SR) N/A
FIRST NAME JOEL

MIDDLE NAME CAPITO

25. MOTHER'S MAIDEN NAME

SURNAME GRATA

FIRST NAME FLORA

MIDDLE NAME FERNANDEZ (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
GRADUATE
HONORS
(Write in full) D
full) (if not graduated) RECEIVED
From To

ELEMENTARY ORAS WEST ELEMENTARY SCHOOL ELEMENTARY 2003 2008 N/A 2008 N/A

VOCATIONAL
SECONDARY / ORAS NATIONAL HIGH SCHOOL HIGH SCHOOL 2009 2012 N/A 2012 N/A

EASTERN SAMAR STATE UNIVERSITY ASSOCIATE IN COMPUTER SCIENCE

2012 2014 N/A 2014 N/A
(ESSU) CAN-AVID CAMPUS (ACS)
TRADE
COURSE HOLY VIRGIN OF SALVACION
BACHELOR OF ELEMENTARY
COLLEGE FOUNDATION COLLEGE INC. TACLOBAN 2017 2021 N/A 2021 N/A
EDUCATION
CITY
GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE 01/24/2024 CS FORM 212 (Revised 2017), Page 1 of 4

by naturalization
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

(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) MONTHLY STATUS OF
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)
12/12/2022 PRESENT FARM WORKER I ARTECHE NATIONAL AGRICULTURAL SCHOOL 13,305.00 2 REGULAR Y

7/1/2018 11/12/2022 FARM WORKER ARTECHE NATIONAL AGRICULTURAL SCHOOL 12,504.00 1 CASUAL Y

1/25/2015 6/30/2018 ACCOUNTING AIDE ARTECHE NATIONAL AGRICULTURAL SCHOOL 6,900.00 N/A JOB ORDER Y

4/1/2014 1/20/2015 LETTER CARRIER PHIL POST - ORAS POST OFFICE 4,500.00 N/A CONTRACTUAL Y

(Continue on separate sheet if necessary)

SIGNATURE DATE 01/24/2024 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

(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

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

COMPUTER LITERATE N/A N/A

FARMING N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 01/24/2024 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
the last 6 months
RENATO T. PICANA, Ph.D. ORAS, EASTERN SAMAR 09109662274 3.5 cm. X 4.5 cm
(passport size)
09085867369/
MAXIMA MAURINE L. TONOG ORAS, EASTERN SAMAR
09777109317 With full and handwritten
name tag and signature over
printed name
MARIETTA M. PALIGUTAN ORAS, EASTERN SAMAR 09268755823
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 (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of Issuance
Government Issued ID: TIN

ID/License/Passport No.: 725-111-591-000

Signature (Sign inside the box)
01/24/2024
Date/Place of Issuance: 07/04/2018
Date Accomplished Right Thumbmark

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

RENATO T.PICAÑA,Ph.D.
Person Administering Oath

CS FORM 212 (Revised 2017), Page 4 of 4