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 CAÑADA
NAME EXTENSION (JR., SR)
FIRST NAME JAY GABRIEL
MIDDLE NAME ANTIG
3. DATE OF BIRTH
(mm/dd/yyyy) 02/10/2007 16. CITIZENSHIP
4. PLACE OF BIRTH Mandaue City, Cebu If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX MALE
17. RESIDENTIAL ADDRESS PUROK 1
6 CIVIL STATUS
House/Block/Lot No. Street
Guinsanga-an
SINGLE
Subdivision/Village Barangay
INOPACAN LEYTE
7. HEIGHT (m) 1.54
City/Municipality Province
8. WEIGHT (kg) 46 ZIP CODE 6522
18. PERMANENT ADDRESS PUROK 1
9. BLOOD TYPE B+
House/Block/Lot No. Street
Guinsanga-an
10. GSIS ID NO. N/A
Subdivision/Village Barangay
INOPACAN LEYTE
11. PAG-IBIG ID NO. N/A
City/Municipality Province
12. PHILHEALTH NO. N/A ZIP CODE 6522
13. SSS NO. N/A 19. TELEPHONE NO. 09396120039
14. TIN NO. N/A 20. MOBILE NO. N/A
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)
FIRST NAME N/A
N/A N/A N/A
MIDDLE NAME N/A
OCCUPATION N/A
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME CAÑADA
NAME EXTENSION (JR., SR) N/A
FIRST NAME EDELITO
MIDDLE NAME BAUYOT
25. MOTHER'S MAIDEN NAME
SURNAME CAÑADA
FIRST NAME EMELINDA
MIDDLE NAME ANTIG (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
HIGHEST LEVEL/ SCHOLARSHIP/
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE
UNITS
YEAR
ACADEMIC
LEVEL (Write in full) GRADUATED HONORS
(Write in full) EARNED
(if not graduated) RECEIVED
From To
ELEMENTARY INOPACAN CENTRAL SCHOOL PRIMARY SCHOOL GRADUATE N/A
SECONDARY MARAO NATIONAL HIGH SCHOOL SECONDARY SCHOOL COMPLETER N/A
VOCATIONAL /
N/A N/A N/A N/A N/A N/A N/A
TRADE
COURSE
COLLEGE N/A N/A N/A N/A N/A N/A 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
IV. CIVIL SERVICE ELIGIBILITY
27. LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEE BARANGAY RATING DATE OF
ELIGIBILITY / DRIVER'S LICENSE (If Applicable) EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
CONFERMENT NUMBER Date of
Validity
N/A N/A N/A N/A 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
28. INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
(mm/dd/yyyy) DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY GRADE (if STATUS OF
POSITION TITLE (Write in full/Do not abbreviate) (Write in SALARY applicable)& STEP
APPOINTMENT
full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To (Y/ N)
N/A 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 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
CAREER GUIDANCE 04/13/23 04/14/23 12.0 MARAO NATIONAL HIGH SCHOOL
SADE( SONS AND DAUGHTER ENCOUNTER ) 28/02/2025 28/03/2025 12.0 POBLACION INOPACAN LEYTE
(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)
DANCING
SINGING
DRAWING
COOKING
EDITING( CANVA )
(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:
________________________________
35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court?
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?
If YES, give details:
________________________________
________________________________
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? ________________________________
________________________________
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:
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:
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
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:
b. Are you a person with disability?
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
4.5 cm. X 3.5 cm
ANGELIE S. PERAS INOPACAN, LEYTE 9102542589 (passport size)
ARNOLD M. CONSULAR HINDANG, LEYTE 9207374278 Computer generated
or photocopied picture
is not acceptable
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: N/A
ID/License/Passport No.: N/A
Signature (Sign inside the box)
Date/Place of Issuance: N/A
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
