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 Sicat
NAME EXTENSION (JR., SR
FIRST NAME Rose Ann

MIDDLE NAME Tolentino

3. DATE OF BIRTH
(mm/dd/yyyy) 3/9/1987 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH Sucol, Calumpit, Bulacan If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male ✘ Female

Single ✘ Married 17. RESIDENTIAL ADDRESS Purok 2

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. S
Ca
Other/s:
Subdivision/Village Ba
Calumpit Bu
7. HEIGHT (m) 1.524 m
City/Municipality Pr
8. WEIGHT (kg) 50 kg. ZIP CODE 3003

18. PERMANENT ADDRESS Purok 2

9. BLOOD TYPE o
House/Block/Lot No. S
Ca
10. GSIS ID NO. n/a
Subdivision/Village Ba

11. PAG-IBIG ID NO.

Calumpit
City/Municipality Pr

12. PHILHEALTH NO. ZIP CODE 3003

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

14. TIN NO. 20. MOBILE NO. 09263132744

15. AGENCY EMPLOYEE NO. n/a 21. E-MAIL ADDRESS (if any) ratsicat0309@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME Sicat 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) N/A
FIRST NAME Jayson

MIDDLE NAME Villarta

OCCUPATION Production Operator

EMPLOYER/BUSINESS NAME Universal Robina Corporation

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME (Deceased) Tolentino

NAME EXTENSION (JR., SR)
FIRST NAME Gaudencio
 MIDDLE NAME Talavera

25. MOTHER'S MAIDEN NAME

SURNAME Mangalindan

FIRST NAME Loida

MIDDLE NAME De Leon (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 Calumpit Central School ELEMENTARY 1994 2000 Graduated

SECONDARY
VOCATIONAL /
San Marcos High School High School 2000 2004 Graduated

n/a n/a n/a n/a n/a

TRADE
COURSE
COLLEGE Bulacan State University Bachelor of Science in Information Technology 2004 2008 Graduated

GRADUATE STUDIES n/a n/a n/a n/a n/a

(Continue on separate sheet if necessary)

SIGNATURE DATE
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
Caniogan
Barangay
Bulacan
Province
3003

Street
Caniogan
Barangay
Bulacan
Province

N/A

09263132744

ratsicat0309@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

 (Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2000 with honor

municipal
2004 scholarship/
with honor

n/a n/a
Cong. Willy
S.Y
2008
Alvarado
Scholarship
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 SPECIAL DATE OF
RATING
LAWS/ CES/ CSEE BARANGAY EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable)
ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

LET (LICENSURE EXAMINATION FOR TEACHERS) 82.0 3/19/2019 ARELLANO UNIVERSITY, MANILA

MARCELO H. DEL PILAR HIGH SCHOOL,

CIVIL SERVICE SUBPROFESSIONAL 82.0 3/24/2018
BULACAN

(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. SALARY/ JOB/ PAY
INCLUSIVE DATES (mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
MONTHLY
(Write in full/Do not (Write in SALARY
applicable)& STEP
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To

Data Search Associates (Title Search

June 10, 2010 May 10, 2018 Datascope Communications (Phils.) Inc. 15,000.00 0-0
Examiner)
Oct-09 Mar-10 Data Encoder Burlington Industries 10,000.00 0-0

Dec-08 Jun-09 Admin Staff Marlow Navigation Training Center 11,000.00 0-0
 (Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 21
 LICENSE (if applicable)

NUMBER Date of
Validity

3/9/2022

on separate sheet if necessary)

duties should be indicated in the attached Work Experience sheet. GOV'T

SERVICE

STATUS OF
APPOINTMENT

(Y/
N)
REGULAR N

contractual n

contractual n
on separate 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

para-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)

n/a n/a

(Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

para-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)

n/a

eparate 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
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? shift of career
________________________________
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 tak
the last 6 m
3.5 cm. X 4
(passport

With full and h

name tag and sig
printed n

Computer ge
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete or photocopie
is not acce
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 PHOT
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.:
Signature (Sign inside the box)

Date/Place of Issuance:
Date Accomplished Right Thum

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

Person Administering Oath

CS FORM 212 (R
 If YES, give details: ________________________________
________________________________

If YES, give details: ________________________________

________________________________

If YES, give details: ________________________________

________________________________

If YES, give details: ________________________________

________________________________

If YES, give details: ________________________________

________________________________

✘ NO

✘ NO

✘ NO
If YES, give details (country):

✘ NO

✘ NO

✘ NO

ID picture taken within

the last 6 months
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten

name tag and signature over
printed name

Computer generated
or photocopied picture
is not acceptable

PHOTO
 Right Thumbmark

, affiant exhibiting his/her validly issued government ID as indicated above.

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