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 aga
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 PAGUL A YAN
NAME EXTENSION (JR., SR
FIRST NAME REGIN JASPER

MIDDLE NAME SALIGANAN N/A

3. DATE OF BIRTH
(mm/dd/yyyy) 10/1/1983 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH GONZAGA, CAGAYAN If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX ✘ Male Female

Single ✘ Married 17. RESIDENTIAL ADDRESS ZO

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. S
ALIMAN
Other/s:
Subdivision/Village Ba
PEÑABLANCA CAGAYA
7. HEIGHT (m) 1.73
City/Municipality Pr
8. WEIGHT (kg) 80 ZIP CODE 3502

18. PERMANENT ADDRESS ZO

9. BLOOD TYPE "O"
House/Block/Lot No. S
ALIMAN
10. GSIS ID NO. N/A
Subdivision/Village Ba
PEÑABLANCA
11. PAG-IBIG ID NO. N/A
City/Municipality Pr

12. PHILHEALTH NO. 040-500-829-593 ZIP CODE 3502

13. SSS NO. N/A 19. TELEPHONE NO. N/A

14. TIN NO. 947-199-557 20. MOBILE NO. +639265244140

15. AGENCY EMPLOYEE NO. 15E210365 21. E-MAIL ADDRESS (if any) Jhaspher_33@icloud.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME PAGULAYAN 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) DANIELLE MIKAELLA THERESE TANGUILAN PAGULAYAN
FIRST NAME HAIZEL
JASTINE HAILIE TANGUILAN PAGULAYAN
MIDDLE NAME TANGUILAN
JASTINE GABRIELLE TANGUILAN PAGULAYAN
OCCUPATION TEACHER

EMPLOYER/BUSINESS NAME DEPARTMENT OF EDUCATION

BUSINESS ADDRESS CARIG, TUGUEGARAO CITY

TELEPHONE NO. N/A

24. FATHER'S SURNAME PAGULAYAN

NAME EXTENSION (JR., SR)
FIRST NAME ROBERTO

MIDDLE NAME LINGAN

25. MOTHER'S MAIDEN NAME

SURNAME SALIGANAN

FIRST NAME THERESA

MIDDLE NAME CASTILLO (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

PEÑABLANCA WEST-CENTRAL ELEMENTARY

ELEMENTARY
SCHOOL
PRIMARY EDUCATION 1991 1996 GRADUATED

SECONDARY PEÑABLANCA NATIONAL HIGH SCHOOL HIGH SCHOOL 1996 2000 GRADUATED
VOCATIONAL /

N/A N/A N/A N/A N/A

TRADE
COURSE BACHELOR OF SCIENCE IN INFORMATION
COLLEGE SAINT PAUL UNIVERSITY PHILIPPINES
TECHNOLOGY 2000 2004 GRADUATED

GRADUATE STUDIES N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE CS FORM 212 (Re

L DATA SHEET
rience 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:

ZONE 5
Street
ALIMANNAO HILLS
Barangay
CAGAYAN VALLEY
Province
3502

ZONE 5
Street
ALIMANNAO HILLS
Barangay
CAGAYAN VALLEY
Province

3502

N/A

+639265244140

Jhaspher_33@icloud.com

DATE OF BIRTH (mm/dd/yyyy)

8/31/2003

4/22/2013

2/26/2017

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

1996

2000
 N/A N/A

2004

N/A N/A

parate sheet if necessary)

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

Police Officer Examination 72.8 10/26/2015 Tuguegarao City N/A N/A

Police Entrance Examination 71.1 10/24/2004 Tuguegarao 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/ 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 (Y/
N)
5/15/2015 Present Police Officer 1 Philippine National Police SG 10-0 Permanent Y

12/11/2013 5/15/2015 Police Officer 1 Philippine National Police SG 10-0 Temporary Y

10/24/2008 10/24/2011 Factory Worker Cheertime Electronics Taiwan R.O.C. 30, 000.00 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
INCLUSIVE DATES
29. NAME & ADDRESS OF ORGANIZATION
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / N
From To

N/A N/A N/A N/A N

(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/ SP
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To

INTELLIGENCE ANALYST SEMINAR WORKSHOP 9/21/2015 9/28/2015 40 SPECIALIZED POLICE REGION

SPECIAL COUNTER-INSURGENCY OPERATIONS AND TACTICS 1/14/2015 4/20/2015 N/A SPECIALIZED REGIONAL SPE

PUBLIC SAFETY BASIC RECRUIT COURSE 12/7/2013 1/14/2015 960 MANDATORY REGIONAL TRA
 (Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

COMPUTER LITERATE Medalya ng Papuri

SWIMMING Medalya ng Kasanayan

BIKING Tsapa ng Natatanging Yunit

BASKETBALL Medalya ng Paglaban Sa Manliligalig

Medalya ng Paglilingkod sa Luzon

Medalya ng Papuri
(Continue on separate sheet if necessary)

SIGNATURE DATE
EOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

N/A

te sheet if necessary)

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

CONDUCTED/ SPONSORED BY
(Write in full)

POLICE REGIONAL OFFICE 2

REGIONAL SPECIAL TRAINING UNIT PRO2

REGIONAL TRANING CENTER 2, CAUAYAN, CITY

te sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION

(Write in full)

N/A

te sheet if necessary)

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 NO
YES ✘
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
PSSUPT JEREMIAS E AGLUGUB Tuguegarao City 9053785428 3.5 cm. X 4.5 cm
(passport size)

PSUPT KEVIN T BULAYUNGAN Cauayan City, Isabela 9175629839 With full and handwritten
name tag and signature over
printed name
SPO4 Reynaldo T Marigmen Peñablanca, Cagayan 9272242258
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: PNP ID

ID/License/Passport No.: 15E210365

Signature (Sign inside the box)
11/20/2017
Date/Place of Issuance: Camp Crame, Quezon 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

 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