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CS Form No.

212
Revised 2017

PERSONAL DATA SHEET


WARNING: Any misinterpretation 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 Gonzaga
NAME EXTENSION (JR., SR)
FIRST NAME Lanie

MIDDLE NAME Lopez


3. DATE OF BIRTH
7/16/1963 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH Abucay, Pilar, Sorsogon If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS 432

Widowed Separate House/Block/Lot No. Street


Espartinez Subd., Bagumbayan
Other/s: d Subdivision/Village Barangay
Daraga, Albay
7. HEIGHT (m) 5 '1'
City/Municipality Province
8. WEIGHT (kg) 115 lbs. ZIP CODE 4501
18. PERMANENT ADDRESS 432
9. BLOOD TYPE AB
House/Block/Lot No. Street
Espartinez Subd., Bagumbayan
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A Daraga Albay


City/Municipality Province
12. PHILHEALTH NO. N/A ZIP CODE 4501

13. SSS NO. 03-8540057-4 19. TELEPHONE NO. N/A

14. TIN NO. 117-956-348 20. MOBILE NO. 09207751118

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) lanilop15@gmail.com
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) N/A
FIRST NAME N/A

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME Gonzaga


NAME EXTENSION (JR., SR)
FIRST NAME Conrado

MIDDLE NAME

25. MOTHER'S MAIDEN NAME

SURNAME Lopez

FIRST NAME Alice

MIDDLE NAME Mirasol (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND


HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
UNITS ACADEMIC
LEVEL (Write in full) EARNED
GRADUATED
HONORS
(Write in full) (if not RECEIVED
From To
graduated)
8 th
ELEMENTARY Abucay Elementary School Primary 6/2/1970 3/5/1975 1975
Placer
VOCATIONAL /
SECONDARY Bicol College -High School Secondary 6/5/1975 3/25/1979 1979

International Correspondence Schools Interior Design 10/1/1993 10/25/1994 1994


Bachelor of Science in Commerce Major in
COLLEGE TRADE Divine Word College of Legazpi 7/1/1979 3/16/1983 1983
COURSE Management

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE May 22, 2019

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

Sub Professional N/A 1/30/1982 LEGAZPI CITY N/A N/A

Board For Proffessional Teachers 75.4 8/24/1997 LEGAZPI CITY 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
SERVICE
28. INCLUSIVE DATES SALARY/ JOB/
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY PAY GRADE (if STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To (Y/
N)
International Teams/Greenhills Christian 4000.00
1/1/2008 1/1/2018 Educator,Counselor, Motivator N/A On call N
Fellowship
Department of Social Welfare and
5/15/2015 9/15/2015 Area Supervisor ### N/A Contractual Y
Development-Region V
01/01//1995 10/15/2008 Sales Counselor, District Manager Eternal Plans Incorporation 5000.00 N/A Contractual N
Office Cashier,Bookstore in Charge,
6/1/1994 4/15/1995 Legazpi Hope Christian School 5000.00 N/A Regular N
Kinder 1 Teacher
4/1/1987 4/15/1994 Admin Staff , Branch Manager Christian Literature Crusade 6000.00 N/A Regular N
Intervarsity Christian Fellowship,
1/1/1984 4/30/1986 Volunteer Missionary 3000.00 N/A Contractual N
Batangas City
5/1/1983 5/30/1984 Sales Clerk Magnolia House Legazpi City 150.00 N/A Contractual 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
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (Write in
full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

Starryhost Mission International 1/10/2008 5/22/2019 4 hours Missionary, Community Developer

(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
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) From To Technical/etc)

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


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

(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 theof bureau or office or to the person who has immediate supervision over you in the
chief
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 by any court or tribunal?
YES ✘ NO
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 If YES, give details:
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
YES ✘ NO
(except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
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?
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
a.
items:
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
Fide Academy School Rizal the last 6 months
Pastor Grando Bruzo Street, Guinobatan, Albay
0932-883-9008 3.5 cm. X 4.5 cm
(passport size)
Bicol College High School, Rizal
Margeline S. Madelar Street, Daraga, Albay
0927-827-1115 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 or photocopied picture
is not acceptable
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 PHOTO
filing of 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: SSS

ID/License/Passport No.: 03-8540057-4


Signature (Sign inside the box)
05/22/2019
Date/Place of Issuance: Legazpi 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 of 4

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