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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 cas
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.

I. PERSONAL INFORMATION
2. SURNAME SAN JOSE

FIRST NAME BERNADETTE

MIDDLE NAME DE GUZMAN


3. DATE OF BIRTH
(mm/dd/yyyy)
3/14/1971 16. CITIZENSHIP
Filipino Dual Citi

4. PLACE OF BIRTH VALENZUELA If holder of dual citizenship,

please indicate the details.


5. SEX Male Female

6 CIVIL STATUS Single Married 17. RESIDENTIAL ADDRESS 71


House/Block/Lot No.
Widowed Separated
Other/s:
Subdivision/Village

7. HEIGHT (m) 1.7 m VALENZUELA CITY


City/Municipality
8. WEIGHT (kg) 55 kg ZIP CODE 1443

18. PERMANENT ADDRESS 71


9. BLOOD TYPE B
House/Block/Lot No.

10. GSIS ID NO. BP-20007944116


Subdivision/Village
VALENZUELA CITY
11. PAG-IBIG ID NO. 1060-0093-5246
City/Municipality

12. PHILHEALTH NO. 19-000697360-9 ZIP CODE 1443

13. SSS NO. 03-94292304 19. TELEPHONE NO. 245-0227

14. TIN NO. 176-395-876 20. MOBILE NO. 09258877892

15. AGENCY EMPLOYEE NO. 01680 21. E-MAIL ADDRESS (if any) benettesj@yahoo.com.

II. FAMILY BACKGROUND


22. SPOUSE'S SURNAME SAN JOSE 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME MARVIN BEA MARI SAN JOSE

MIDDLE NAME ESPIRITU

OCCUPATION EMPLOYEE

EMPLOYER/BUSINESS NAME LOCAL GOVERNMENT OF VALENZUELA

BUSINESS ADDRESS KARUHATAN, VALENZUELA CITY

TELEPHONE NO. 352-1000

24. FATHER'S SURNAME DE GUZMAN


NAME EXTENSION (JR., SR)
FIRST NAME FLORENCIO
MIDDLE NAME MARIANO

25. MOTHER'S MAIDEN NAME

SURNAME FRANCISCO

FIRST NAME TERESITA

MIDDLE NAME BORROMEO (Continue on separate sheet

III. EDUCATIONAL BACKGROUND

26. NAME OF SCHOOL PERIOD OF ATTENDANCE


BASIC EDUCATION/DEGREE/COURSE
LEVEL (Write in
(Write in full)
full)
From To

ELEMENTARY PIO ELEMENTARY SCHOOL ELEMENTARY GRADUATE


1977 1983

SECONDARY /
VOCATIONAL COLEGIO DE SAN PASCUAL BAYLON HIGH SCHOOL GRADUATE
1983 1987

N/A

TRADE ADAMSON UNIVERSITY BACHELOR OF SCIENCE IN COMPUTER


COURSE
COLLEGE ENGINEERING 1987 1993

GRADUATE STUDIES N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE
AL DATA SHEET
k Experience Sheet shall cause the filing of administrative/criminal case/s against the person

DS) BEFORE ACCOMPLISHING THE PDS FORM.


(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Filipino Dual Citizenship


by birth by naturalization
Pls. indicate country:

M. GREGORIO ST.
Street
CANUMAY WEST
Barangay

Province
1443

M. GREGORIO ST.
Street
CANUMAY WEST
Barangay

Province

245-0227

09258877892

benettesj@yahoo.com.

23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

BEA MARI SAN JOSE 9/28/2005


(Continue on separate sheet if necessary)

HIGHEST LEVEL/ SCHOLARSHIP/


YEAR
UNITS ACADEMIC
GRADUATED
EARNED HONORS
(if not graduated) RECEIVED

1983

1987

1993

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

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

1/1/2017 present Admin. Asst. III ( Secretary II) Council's Office 16,986.00/m

1/1/2016 12/31/2016 Admin. Asst. III ( Secretary II) Council's Office 16,512.00/m

1/1/2013 12/31/2015 Admin. Asst. III ( Secretary II) Council's Office 16,051.00/m

1/1/2012 12/31/2012 Admin. Asst. III ( Secretary II) Council's Office 14,857.00/m

1/1/2011 12/31/2011 Secretary II Council's Office 13,663.00/m

7/1/2010 12/31/2010 Secretary II Council's Office 12,469.00/m

1/1/2010 6/30/2010 Clerk 1 Mayor's Office 8,080.00/m

7/1/2008 12/31/2009 Clerk 1 Mayor's Office 7,307.00/m

7/1/2007 12/31/2007 Clerk 1 Mayor's Office 6,039.00/m

7/1/2003 6/30/2007 LLSA III Vice Mayor's Office 9,939.00/m

7/2/2001 6/30/2003 LLSA III Vice Mayor's Office 451.77/d


(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 21
LICENSE (if applicable)

NUMBER Date of
Validity

e on separate sheet if necessary)

duties should be indicated in the attached Work Experience sheet.


GOV'T
SERVICE
STATUS OF
APPOINTMENT

(Y/ N)

Casual

Casual

Casual

Casual

Casual

Casual

Casual

Casual

Cont'l

Casual

Casual
e 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

N/A

(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) (mm/dd/yyyy) Supervisory/
Technical/etc)
From To

Strategic Planningg and Work Attitude Program 11/10/2006 16.0 Atty. Thomas
11/11/2006

I survived the Rope Challenge and Team Building 10/19/2002 4 hrs La Corona de
10/19/2002

10/17/2002 10/18/2002 16.0 Meralco Foun


Intergrated Team Building And Work Attitude Program
(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


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

JOGGING N/A

WATCHING MOVIES

SURFING THE NET

(Continue on separate sheet if necessary)

SIGNATURE DATE
E / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

parate sheet if necessary)


S ATTENDED
5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

Atty. Thomas M. Valmonte (Speaker & Facilitator)

La Corona de Pagsanjan Resort

Meralco Foundation
parate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in
full)

N/A

parate 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

b. within the fourth degree (for Local Government Unit - Career Employees)? YES

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? ________________________________
________________________________
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
the last 6 mon
Dra. Grace Galino Balubaran Malinta 0922-8799717 3.5 cm. X 4.5
(passport siz

PB Rhoel De guzman PULO 9228592247 With full and hand


name tag and signa
printed nam
Former Kgd. Catalina Moreno Malinta 0942-5830610
Computer gene
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied p
is not accepta
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: SSS

ID/License/Passport No.: 03-94292304


Signature (Sign inside the box)
May 10, 2017
Date/Place of Issuance: Valenzuela Branch
Date Accomplished Right Thumbm

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

Person Administering Oath

CS FORM 212 (Rev


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