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 a
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 DOMINGO
NAME EXTENSION (JR.,
FIRST NAME MARITES
MIDDLE NAME OBAÑA
3. DATE OF BIRTH
(mm/dd/yyyy) 10/21/1988 16. CITIZENSHIP ✘ Filipino Dual Citizenship
✘ by birth by
4. PLACE OF BIRTH SANTIAGO CITY If holder of dual citizenship, Pls. indicate c
please indicate the details.
5. SEX Male ✘ Female

Single ✘ Married 17. RESIDENTIAL ADDRESS

6 CIVIL STATUS
Widowed Separated House/Block/Lot No.
PUROK 1
Other/s:
Subdivision/Village B
DIFFUN Q
7. HEIGHT (m) 5'3"
City/Municipality P
8. WEIGHT (kg) 54kg ZIP CODE 3401

18. PERMANENT ADDRESS

9. BLOOD TYPE "A+"
House/Block/Lot No.
PUROK 1
10. GSIS ID NO. N/A
Subdivision/Village B
DIFFUN
11. PAG-IBIG ID NO. 121200305553
City/Municipality P
12. PHILHEALTH NO. 06-200660347-0 ZIP CODE 3401

13. SSS NO. 01-2690217-6 19. TELEPHONE NO. N/A

14. TIN NO. 701-860-752 20. MOBILE NO. 09752506562

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) maritesdomingo39@gmail.c
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME DOMINGO 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME ALVIN REY N/A ALLYSSA MAE OBAÑA DOMINGO
MIDDLE NAME MALAQUE
OCCUPATION PHILIPPINE NATIONAL POLICE
EMPLOYER/BUSINESS NAME PHILIPPINE NATIONAL POLICE
BUSINESS ADDRESS CAMP CRAME QUEZON CITY
TELEPHONE NO. 41885
24. FATHER'S SURNAME OBAÑA
NAME EXTENSION (JR., SR)
FIRST NAME MARCELINO SR.

MIDDLE NAME ESTELONG

25. MOTHER'S MAIDEN NAME
 SURNAME CALIJA
FIRST NAME TERESITA
MIDDLE NAME TAMIAO (Continue on separate sheet if necessa

III. EDUCATIONAL BACKGROUND

HIGHEST
26. NAME OF SCHOOL PERIOD OF ATTENDANCE LEVEL/
BASIC EDUCATION/DEGREE/COURSE UNITS
LEVEL (Write in EARNED
(Write in full)
full) (if not
From To graduated)

GRADUAT
ELEMENTARY GULAC ELEMENTARY SCHOOL ELEMENTARY 1992 1998
ED
VOCATIONAL
SECONDARY / DIFFUN HIGH SCHOOL HIGH SCHOOL 1998 2002 GRADUATED

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

TRADE GRADUAT
QUIRINO STATE COLLEGE BS CRIMINOLOGY 2006 2009
COLLEGE
COURSE QUIRINO STATE UNIVERSITY PROFESSIONAL EDUCATION SUBJECT 2018 2019
ED 18
UNITS
GRADUATE STUDIES UNIVERSITY OF LA SALETTE, INC. MS CRIMINOLOGY 2017 PRESENT 33 UNITS

(Continue on separate sheet if necessary)

SIGNATURE DATE JULY

CS FORM
L DATA SHEET
xperience Sheet shall cause the filing of administrative/criminal case/s against the person

S) BEFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR) N/A

Dual Citizenship
✘ by birth by naturalization
Pls. indicate country:

Street
CAJEL
Barangay
QUIRINO
Province
3401

Street
CAJEL
Barangay
QUIRINO
Province

N/A

09752506562

maritesdomingo39@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

3/12/2009

01/17/1958
 9/10/1960

(Continue on separate sheet if necessary)

YEAR SCHOLARSHIP/
GRADUATED ACADEMIC HONORS
RECEIVED

1998 N/A

2002 N/A

N/A N/A

2009 SCHOOL
2019 TRIBUNAL

N/A N/A
separate sheet if necessary)

JULY 04,2019
CS FORM 212 (Revised 2017), Page 1 of 4
 IV. CIVIL SERVICE ELIGIBILITY
27. LICENSE (if applic
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

CRIMINOLOGY BOARD PASSER 75.0 OCT.2014 TUGUEGARAO CITY 0105988

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE

28. INCLUSIVE DATES SALARY/ JOB/ PAY

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

CONTRACT OF
4/7/2019 PRESENT PROCUREMENT STAFF QUIRINO STATE UNIVERSITY 10000.00 N/A SERVICE
CONTRACT OF
4/1/2019 06/28/2019 PROCUREMENT STAFF QUIRINO STATE UNIVERSITY 10000.00 N/A SERVICE
CONTRACT OF
9/7/2018 12/29/2018 PROCUREMENT STAFF QUIRINO STATE UNIVERSITY 10000.00 N/A SERVICE
CONTRACT OF
06/022017 5/7/2018 SECURITY OFFICER QUIRINO STATE UNIVERSITY 7500.00 N/A SERVICE
 (Continue on separate sheet if necessary)
SIGNATURE DATE JULY 04,2019
CS FORM 212 (Revised 2017),
ERVICE ELIGIBILITY
LICENSE (if applicable)

Date of
Validity

separate sheet if necessary)

GOV'T
SERVICE

(Y/
N)
N

N
separate sheet if necessary)
JULY 04,2019
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

(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 ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
PROGRAMS (Write in full) Supervisory/ (Write in fu
(mm/dd/yyyy) Technical/etc)
From To
DEVELOPING LEARNER'S LIFE COMPETENCIES THROUGH
INNOVATIVE LEARNING PLANS USING OUTCOMES BASED 04/27/2019 04/29/2019 24HOURS TECHNICAL ST. JUDE TRAINING CENTE
EDUCATION(OBE)FRAMEWORK
 (Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)
full)
DRIVING N/A N/A

COMPUTER LITERATE

(Continue on separate sheet if necessary)

SIGNATURE DATE JULY 04, 2019
CS FORM 212 (Revised 2017),
 NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

N/A

separate sheet if necessary)

TRAINING PROGRAMS ATTENDED

ng taken for the last five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

ST. JUDE TRAINING CENTER

separate sheet if necessary)

MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(Write in
full)
N/A

separate sheet if necessary)

JULY 04, 2019
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:

________________________________
a. Have you ever been found guilty of any administrative offense? ________________________________
35. 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
YES ✘ NO
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, 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 (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 YES ✘ NO
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 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
MR. ROMEO B. NANGLIHAN JR. AURORA WEST,DIFFUN,QUIRINO 09368395050 the last 6 months
3.5 cm. X 4.5 cm
ANDRES (passport size)
EDITHA C. CAILIN BONIFACIO,DIFFUN,QUIRINO
09278386070
With full and handwritten
ANDRES BONIFACIO,DIFFUN,
MRS.VIOLETA BENIGNO QUIRINO
09166647539 name tag and signature over
printed name
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and Computer generated
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the or photocopied picture
Philippines. I authorize the agency head/authorized representative to verify/validate the contents stated herein. is not acceptable

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.)

Government Issued ID: PRC

ID/License/Passport No.: 0105988

Signature (Sign inside the box)

JULY 04, 2019

Date/Place of Issuance: 05/09/2017/TUGUEGARAO CITY
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this JULY 04, 2019 , affiant exhibiting his/her validly issued government ID as indicated above.

ANGELINA D. AMBONON, DPA.

Person Administering Oath

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

 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