Vous êtes sur la page 1sur 10

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 agai
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

I. PERSONAL INFORMATION
2. SURNAME GENOTIVA
NAME EXTENSION (JR., SR)
FIRST NAME JESSICA

MIDDLE NAME ESPINOLA


3. DATE OF BIRTH
(mm/dd/yyyy) 12/23/1996 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by naturalizat
4. PLACE OF BIRTH NAGA CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

✘ Single Married 17. RESIDENTIAL ADDRESS NO. 80 AZUCENA


6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
NAGA CITY SUBDIVISION CONCEPCION PEQUEÑA
Other/s:
Subdivision/Village Barangay
NAGA CAMARINES SUR
7. HEIGHT (m) 1.55
City/Municipality Province
8. WEIGHT (kg) 50 ZIP CODE
18. PERMANENT ADDRESS NO. 80 AZUCENA
9. BLOOD TYPE
House/Block/Lot No. Street
NAGA CITY SUBDIVISION CONCEPCION PEQUEÑA
10. GSIS ID NO.
Subdivision/Village Barangay
NAGA CAMARINES S
11. PAG-IBIG ID NO. 1212-3832-8307
City/Municipality Province
12. PHILHEALTH NO. 1002-5347-4062 ZIP CODE 4400

13. SSS NO. 34-8006715-2 19. TELEPHONE NO. N/A

14. TIN NO. 20. MOBILE NO. 09611864809

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) jessicagenotiva1996@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/d
NAME EXTENSION (JR., SR)
FIRST NAME 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 GENOTIVA


NAME EXTENSION (JR., SR)
FIRST NAME FELIPE

MIDDLE NAME YONGON

25. MOTHER'S MAIDEN NAME PILAR ESPINOLA

SURNAME ESPINOLA

FIRST NAME PILAR

MIDDLE NAME VALENCIA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND


HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE LEVEL/
26. PERIOD OF ATTENDANCE YEAR
UNITS
LEVEL (Write in full) EARNED
GRADUATED
(Write in full) (if not
From To
graduated)
ELEMENTARY NAGA CENTRAL SCHOOL 2 PRIMARY EDUCATION 6/1/2002 3/31/2009 2009
VOCATIONAL /
SECONDARY ATENEO DE NAGA UNIVERSITY SECONDARY 6/1/2009 3/18/2013 2013

AB-BACHELOR OF SECONDARY
COLLEGE TRADE ATENEO DE NAGA UNIVERSITY 6/1/2013 3/24/2018 2018
COURSE EDUCATION MAJOR IN ENGLISH
GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), P
e/s against the

For CSC use only)

turalization

ry:

EQUEÑA

SUR

EQUEÑA

NES SUR

RTH (mm/dd/yyyy)

SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED

PBED
STEP-UP
SCHOLAR
SHIP,
CHED
GRANT-
ed 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

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
SERVICE
28. INCLUSIVE DATES SALARY/ JOB/
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY PAY GRADE (if STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To (Y/
N)
CONTRACT
6/18/2018 PRESENT TEACHER HOLY ROSARY MINOR SEMINARY ### N/A N/A
UAL

(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
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (Write in
full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

CITY YOUTH OFFICIALS 4/1/2015 4/1/2016 2 MONTHS 4TH CITY YOUTH COUNCILOR

(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
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) From To Technical/etc)

DIVISION CLINIQUING OF REGIONAL SCHOOLS


10/21/2019 10/25/2019 40 HOURS N/A DEPED-NAGA
PRESS CONFERENCE QUALIFIERS
IN-SERVICE TRAINING 2019 7/22/2019 7/24/2019 24 HOURS N/A
HOLY ROSARY MINOR SEMINARY

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 33.
(Write in full) (Write
in full)
WRITING DEPARTMENTAL SERVICE AWARD
2ND PLACE - FR. GODOFREDO ALINGAL ESSAY
PUBLIC SPEAKING
WRITING CONTEST

(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 theof bureau or office or to the person who has immediate supervision over you in the
chief
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
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 YES ✘ NO
(except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
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?
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
a.
items:
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
ELIAS ANGELES ST., NAGA the last 6 months
REV. FR. ENRICO JULIAN PAGLINAWAN CITY
9088841420 3.5 cm. X 4.5 cm
(passport size)
OCAMPO ST., BRGY,
DR. ORFELINA O. TUY BAGUMBAYAN SUR, NAGA 9988853201 With full and handwritten
CITY name tag and signature over
printed name

Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct or photocopied picture
is not acceptable
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 PHOTO
filing of 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: PRC

ID/License/Passport No.: 1798746


Signature (Sign inside the box)

Date/Place of Issuance: 11/19/2019 - NAGA 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 4