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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 ag
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

I. PERSONAL INFORMATION
2. SURNAME PATOSA
NAME EXTENSION (JR., SR
FIRST NAME SHIRLYN JOY

MIDDLE NAME CAPINPIN


3. DATE OF BIRTH
(mm/dd/yyyy) 12/23/1986 16. CITIZENSHIP Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH PAG-ANTAYAN, CANTILAN, SDS If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male Female

Single Married 17. RESIDENTIAL ADDRESS P-6


6 CIVIL STATUS
Widowed Separated House/Block/Lot No. S
PAG-A
Other/s:
Subdivision/Village Ba
CANTILAN SURIGA
7. HEIGHT (m)
City/Municipality Pr
8. WEIGHT (kg) 76 Kg. ZIP CODE 8317

18. PERMANENT ADDRESS P-6


9. BLOOD TYPE
House/Block/Lot No. S
PAG-A
10. GSIS ID NO.
Subdivision/Village Ba
CANTILAN
11. PAG-IBIG ID NO. 1211-8385-6325
City/Municipality Pr

12. PHILHEALTH NO. 18-050119157-2 ZIP CODE 8317

13. SSS NO. 08-1654046-6 19. TELEPHONE NO.

14. TIN NO. 475-178-230 20. MOBILE NO. 09127082129

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any)

II. FAMILY BACKGROUND


22. SPOUSE'S SURNAME PATOSA 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) CASSIE ISHBEL C. PATOSA
FIRST NAME EDIEMAR

MIDDLE NAME ESTRADA

OCCUPATION OFW

EMPLOYER/BUSINESS NAME PETROMIN EXPRESS

BUSINESS ADDRESS RIYADH, SAUDI ARABIA

TELEPHONE NO.

24. FATHER'S SURNAME CAPINPIN


SR
FIRST NAME RODRIGO
MIDDLE NAME dela CRUZ

25. MOTHER'S MAIDEN NAME GANAS

SURNAME CAPINPIN

FIRST NAME SHIRLY

MIDDLE NAME MARATON (Continue on separate sheet if necessary

III. EDUCATIONAL BACKGROUND


NAME OF SCHOOL HIGHEST LEVEL/
26. BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE UNITS
LEVEL (Write in EARNED
(Write in full)
full) (if not graduated)
From To

ELEMENTARY CANTILAN PILOT SCHOOL 6/5/1995 3/30/2000

SECONDARY /
VOCATIONAL PANIKIAN NATIONAL HIGH SCHOOL 6/5/2000 3/30/2004

TRADE
COURSE BACHELOR OF TECHNICIAN TEACHER
COLLEGE SURIGAO DEL SUR STATE UNIVERSITY
EDUCATION-HELE
6/5/2004 3/30/2008

MASTER TEACHER IN TECHNOLOGY


GRADUATE STUDIES SURIGAO DEL SUR STATE UNIVERSITY
EDUCATION-FOOD 27
(Continue on separate sheet if necessary)

SIGNATURE DATE June

CS FORM
L DATA SHEET
erience Sheet shall cause the filing of administrative/criminal case/s against the person

EFORE ACCOMPLISHING THE PDS FORM.


(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Dual Citizenship

by naturalization

Pls. indicate country:

Street
PAG-ANTAYAN
Barangay
SURIGAO DEL SUR
Province
8317

Street
PAG-ANTAYAN
Barangay
SURIGAO DEL SUR
Province

09127082129

DATE OF BIRTH (mm/dd/yyyy)

11/28/2013
(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2000

2004

2008

parate sheet if necessary)

June 8, 2017

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 ap
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

LET 75.6 9/26/2015 CAGAYAN DE ORO CITY 1401429

(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
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

GLEN WALACE CO ARCHITECTURAL


1/5/2009 7/5/2009 PROJECT COORDINATOR 9000.00
FIRM
7/10/2009 4/15/2015 SUPERVISOR CARRASCAL CALTEX STATION 11500.00
(Continue on separate sheet if necessary)

SIGNATURE DATE 6/8/2017

CS FORM 212 (Revised 20


LICENSE (if applicable)

Date of
Validity

12/23/2018

arate sheet if necessary)

GOV'T
SERVICE

(Y/
N)
arate sheet if necessary)

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 /
From To

CONSUELO NATIONAL HIGH SCHOOL 11/3/2016 4/7/2017 VOLUNTEER TEACHER

(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/
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To
(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


MEMBERS
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

BAKING

CAKE DECORATING

TABLE SKIRTING

(Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

VOLUNTEER TEACHER

eparate sheet if necessary)


ROGRAMS ATTENDED
five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)
eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

eparate sheet if necessary)

6/8/2017
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:


________________________________

a. Have you ever been found guilty of any administrative offense? YES NO
35.

If YES, give details:


________________________________
________________________________
YES NO
b. Have you been criminally charged before any court?
If YES, give details:
________________________________
Date Filed:
________________________________
Status of Case/s:
YES NO
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:
________________________________
YES 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? ________________________________
YES NO FINISHED CONTRACT
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? YES 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? YES 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):

40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA YES NO
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?
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
RANULFO G. DIAZ, T-II LININTIAN, CANTILAN, SDS 3.5 cm. X 4.5 cm
(passport size)

REMESON TRUGILLO, PRINCIPAL I PANIKAIN, CARRASCAL, SDS With full and handwritten
name tag and signature over
printed name
DORIE T. GEDUCOS TANDAG CITY
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:

ID/License/Passport No.: 1401429


Signature (Sign inside the box)
6-8-2017
Date/Place of Issuance: 3/30/2016-BUTUAN CITY
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 o


If YES, give details (country):
, affiant exhibiting his/her validly issued government ID as indicated above.

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