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 MIMBANTAS
NAME EXTENSION (JR., SR) N/A
FIRST NAME JAMAL
MIDDLE NAME ORIDA
3. DATE OF BIRTH
(mm/dd/yyyy) 1/31/1996 16. CITIZENSHIP FILIPINO✓
by Birth ✓
4. PLACE OF BIRTH GENERAL SANTOS CITY If holder of dual citizenship, Pls. indicate country:PHILIPPINES
please indicate the details.
5. SEX MALE
17. RESIDENTIAL ADDRESS N/A SAN ANTONIO
6 CIVIL STATUS SINGLE
House/Block/Lot No. Street
N/A TUBOD
Subdivision/Village Barangay
ILIGAN CITY LANAO DEL NORTE
7. HEIGHT (m) 169.0
City/Municipality Province
8. WEIGHT (kg) 68.25 ZIP CODE 9200
18. PERMANENT ADDRESS N/A SAN ANTONIO
9. BLOOD TYPE O+
House/Block/Lot No. Street
N/A TUBOD
10. GSIS ID NO. N/A
Subdivision/Village Barangay
ILIGAN CITY LANAO DEL NORTE
11. PAG-IBIG ID NO. 1212-1485-6727
City/Municipality Province
12. PHILHEALTH NO. 170504287338 ZIP CODE 9200
13. SSS NO. 0942-730-218 19. TELEPHONE NO. N/A
14. TIN NO. 715059474 20. MOBILE NO. 0938-234-1199
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]
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
MIDDLE NAME
OCCUPATION
EMPLOYER/BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.
24. FATHER'S SURNAME MIMBANTAS 7/4/1966
NAME EXTENSION (JR., SR) N/A
FIRST NAME BATALO
MIDDLE NAME TANGGOL
25. MOTHER'S MAIDEN NAME
SURNAME ORIDA 4/16/1970
FIRST NAME MOMBAWERA
MIDDLE NAME BUCUA (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
HIGHEST LEVEL/ SCHOLARSHIP/
26. NAME OF SCHOOL PERIOD OF ATTENDANCE YEAR
LEVEL (Write in BASIC EDUCATION/DEGREE/COURSE
(Write in full)
UNITS
GRADUATED
ACADEMIC
HONORS
full) EARNED
(if not graduated) RECEIVED
From To
ELEMENTARY TALUB ELEMENTARY SCHOOL GRADE 1-GRADE 6 2002 2007 GRADUATED 2007 N/A
SECONDARY
UNDA MEMORIAL NATIONAL AGRICULTURAL 1ST YEAR- 4th YEAR 2008 2011 GRADUATED
SCHOOL 2011 N/A
VOCATIONAL /
N/A N/A N/A N/A N/A N/A N/A
TRADE
COURSE
COLLEGE LAKE LANAO COLLEGE INCORPORATED BACHELOR OF SCIENCE IN CRIMINOLOGY 2016 2020 GRADUATED 2020 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
CS FORM 212 (Revised 2017), Page 1 of 4
RA 11131
27. LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER RATING DATE OF
SPECIAL LAWS/ CES/ CSEE (If Applicable) EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT NUMBER Date of
Validity
RA 11131/ REGISTERED CRIMINOLOGIST 75.0 02/2,3&4/2024 CAGAYAN DE ORO CITY 0258890 1/31/2027
NON PROFESSIONAL DRIVER LICENSE N/A 11/15/2020 ILIGAN CITY MO2-20- 1/31/2025
021415
(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
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY GRADE (if STATUS OF
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To (Y/ N)
5/2/2024 7/31/2024 COLLEGE INSTRUCTOR IQRA DEVELOPMENT ACADEMY 4000.00 N/A CONTRACT OF N
SERVICE
10/25/2015 2/15/2016 SERVICE CREW JOLLIBEE GENSAN CROSSING MAKAR 9000.00 N/A REGULAR 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
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
INCLUSIVE DATES OF
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE Type of LD
NUMBER OF HOURS
( Managerial/ CONDUCTED/ SPONSORED BY
(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
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. NON-ACADEMIC DISTINCTIONS / RECOGNITION (Write in full) 33. (Write in
full)
COMPUTER MICROSOFT LITERATE N/A N/A
SPORTS
SINGING
(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,
a. within the third degree?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
________________________________
NO
35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
NO
________________________________
b. Have you been criminally charged before any court?
If YES, give details:
________________________________
Date Filed: NO
________________________________
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:
________________________________
NO
________________________________
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? ________________________________
NO
________________________________
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: NO
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: NO
39. Have you acquired the status of an immigrant or permanent resident of another country?
If YES, give details (country):
NO
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: MARANAO
b. Are you a person with disability?
If YES, please specify ID No: NO
c. Are you a solo parent?
If YES, please specify ID No: 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
4.5 cm. X 3.5 cm
AMENOLLAH MANOTOD SANTA ELENA, BAYANIHAN VILLAGE,
ILIGAN CITY 9269051612 (passport size)
NORALDEN ROMOROS SAN ANTONIO, TUBOD ILIGAN CITY 9654236777 Computer generated
or photocopied picture
is not acceptable
KUYA JULY SAN ANTONIO, TUBOD ILIGAN CITY 9051511806
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. 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: PRC
ID/License/Passport No.: 0258890
Signature (Sign inside the box)
Date/Place of Issuance: 04/15/2024
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
