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 REYES

FIRST NAME KYLIE MAY NAME EXTENSION (JR., SR) N/A

MIDDLE NAME SICLOT

3. DATE OF BIRTH
(mm/dd/yyyy) 05/13/1991 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH MASBATE, MASBATE If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS NONE QUEZON

Widowed Separated House/Block/Lot No. Street
NONE CENTRO
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 1.58 MASBATE MASBATE
City/Municipality Province
8. WEIGHT (kg) 65 ZIP CODE 5400

9. BLOOD TYPE O+
18. PERMANENT ADDRESS NONE QUEZON
House/Block/Lot No. Street

10. GSIS ID NO. CRN 021156004302

NONE CENTRO
Subdivision/Village Barangay
MASBATE MASBATE
11. PAG-IBIG ID NO. 121160147296
City/Municipality Province

12. PHILHEALTH NO. 100251891014 ZIP CODE 5400

13. SSS NO. NONE 19. TELEPHONE NO. (056) 578-1498

14. TIN NO. 478-506-808-000 20. MOBILE NO. 09778425900

15. AGENCY EMPLOYEE NO. 0505150068 21. E-MAIL ADDRESS (if any) [email protected]

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME REYES 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH(mm/dd/yyyy)

NAME EXTENSION (JR., SR) NIKEESHA MIKAELA S. REYES

FIRST NAME OMAR N/A 12/7/2013

MIDDLE NAME ALIM ARCHIEL ANGELO S. REYES 1/10/2015

OCCUPATION N/A CALIX HIENDRICH S. REYES 11/20/2016

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. (O56)578-1498

24. FATHER'S SURNAME SICLOT

NAME EXTENSION (JR., SR)
FIRST NAME GASPAR N/A

MIDDLE NAME YNOT

25. MOTHER'S MAIDEN NAME SONIA ABEJERO BASAS

SURNAME BASAS

FIRST NAME SONIA

MIDDLE NAME ABEJERO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY JOSE ZURBITO SR. ELEMENTARY SCHOOL PRIMARY EDUCATION 1997 2004 N/A 2004 NONE

MASBATE NATIONAL COMPREHENSIVE HIGH

SECONDARY /
VOCATIONAL SCHOOL HIGH SCHOOL 2004 2008 N/A 2008 NONE

N/A

TRADE
COURSE
COLLEGE BICOL UNIVERSITY COLLEGE OF ENGINEERING BS CIVIL ENGINEERING 2008 2013 N/A 2013 NONE

GRADUATE STUDIES N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE June 9, 2017

CS FORM 212 (Revised 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
AQUINAS UNIVERSITY OF LEGAZPI,RAWIS,
CAREER SERVICE PROFESSIONAL 80.15% 10/17/2010 N/A N/A
LEGAZPI CITY

(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/ PAY
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To (Y/
N)
AGRARIAN REFORM PROGRAM DEPARTMENT OF AGRARIAN REFORM-
1/12/2017 PRESENT 18, 217 10-1 PERMANENT YES
TECHNOLOGIST MASBATE
AGRARIAN REFORM PROGRAM DEPARTMENT OF AGRARIAN REFORM-
1/1/2016 12/31/2016 17,730 10-1 PERMANENT YES
TECHNOLOGIST MASBATE
AGRARIAN REFORM PROGRAM DEPARTMENT OF AGRARIAN REFORM-
12/1/2015 12/31/2015 18, 217 10-1 PERMANENT YES
TECHNOLOGIST MASBATE

CARTOGRAPHER DEPARTMENT OF AGRARIAN REFORM-

10/1/2015 11/30/2015 10, 000 N/A JOB ORDER NO
MASBATE

LOCAL GOVERNMENT UNIT OF MASBATE

CONTRACT
5/1/2015 09/30/2015 DRAFTSMAN CITY -CITY PLANNING AND 5,000 N/A NO
OF SERVICE
DEVELOPMENT OFFICE

(Continue on separate sheet if necessary)

SIGNATURE DATE 9/6/2017

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 PROGRAMS ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(Write in full) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To

DEPARTMENT OF AGRARIAN REFORM REGIONAL

ORIENTATION WORKSHOP FOR THE ADOPTION OF 2017 REVISED PERSONAL DATA SHEET 04/21/2017 04/21/2017 8 TECHNICAL
OFFICE-REGION V

DEPARTMENT OF ENVIRONMENT AND NATURAL

RESOURCES-TECHNICAL SERVICES- REGION V
LEARNING MANIFOLD SYSTEM 02/21/2017 02/24/2017 32 TECHNICAL

DR. EMILIO B. ESPINOSA, SR MEMORIAL STATE

BASIC COMPUTER LITERACY, OPERATION AND MAINTAINANCE 08/05/2016 10/07/2016 24 TECHNICAL COLLEGE OF AGRICULTURE AND TECHNOLOGY/
DEPARTMENT OF AGRARIAN REFORM-MASBATE

GEODETIC ENGINEERS OF THE

E-SURVEY SEMINAR 04/02/2016 04/02/2016 8 TECHNICAL PHILIPPINES,INC C/O LANDS MANAGEMENT
SERVICES

DEPARTMENT OF AGRARIAN REFORM REGIONAL

DAR-DENR- GE MEETING 04/28/2016 04/28/2016 8 TECHNICAL
OFFICE-REGION V

BICOL UNIVERSITY COLLEGE OF

EMPLOYABILITY ENHANCEMENT TRAINING 02/19/2013 02/13/2013 8 TECHNICAL
ENGINEERING

DEPARTMENT OF AGRARIAN REFORM-

ORIENTATION TRAINING FOR NEW DEPARTMENT OF AGRARIAN REFORM APPOINTEES 01/27/2016 01/29/2017 24 TECHNICAL
MASBATE
CONSTRUCTION MANPOWER DEVELOPMENT
REINFORCED CONCRETE WORKS 08/24/2012 08/25/2012 16 TECHNICAL FOUNDATION

2011 REGIONAL PICE STUDENTS SUMMIT- ''CE BUILDING THE FUTURE TODAY'' 10/19/2011 10/19/2011 8 TECHNICAL PHILIPPINE INSTITUTE OF CIVIL ENGINEERS. INC.

2011 NATIONAL MIDYEAR CONVENTION - 12TH NATIONAL CIVIL ENGINEERING

STUDENT'S SUMMIT - ''PICE MAKA-R.P.: MEMBERS, KNOWLEDGE, RESPONSIBILITY, 2/7/2011 2/7/2011 8 TECHNICAL PHILIPPINE INSTITUTE OF CIVIL ENGINEERS. INC.
PRESTIGE''

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33. (Write
(Write in full)
in full)
DEPARTMENT OF AGRARIAN REFORM
TECHNICAL DRAFTING IN AUTOCAD NONE
EMPLOYEES ASSOCIATION

WATCHING TELEVISION

SURFING THE INTERNET

LISTENING TO MUSIC

EDITING PICTURES

MANIPULATING E-SURVEY

(Continue on separate sheet if necessary)

SIGNATURE DATE 9/6/2017
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:
________________________________
N/A

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 within
the last 6 months
ATTY. JOSEPH DOMINGO M. ANGUSTIA BRGY. CAYABON, MILAGROS 09198383911 3.5 cm. X 4.5 cm
(passport size)

HERALD R. TAMBAL CROSSING ST., MASBATE CITY 09399225586 With full and handwritten
name tag and signature over
printed name
ENGR. OSCAR F. TEODORO, JR. TIONGSON SUBD., MASBATE CITY 09175029130
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied picture
is not acceptable
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: GSIS UMID

ID/License/Passport No.: CRN-021-1560-0433-1

Signature (Sign inside the box)
01/21/2018
Date/Place of Issuance: MASBATE CITY
Date Accomplished Right Thumbmark

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

FELIX E. FRUTO
Person Administering Oath

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