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 aga
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
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

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

Single Married 17. RESIDENTIAL ADDRESS

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. S
N/A
Other/s:
Subdivision/Village Bar
7. HEIGHT (m)
City/Municipality Pro
8. WEIGHT (kg) ZIP CODE 2420

18. PERMANENT ADDRESS 350

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

10. GSIS ID NO.

Subdivision/Village Bar

11. PAG-IBIG ID NO.

City/Municipality Pro

12. PHILHEALTH NO. ZIP CODE 2420

13. SSS NO. 19. TELEPHONE NO. N/A

14. TIN NO. 20. MOBILE NO. 09065943427 / 09507202927

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any)

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME N/A

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME

NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

25. MOTHER'S MAIDEN NAME

 SURNAME

FIRST NAME

MIDDLE NAME (Continue on separate sheet if necessary

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY ELEMENTARY N/A

SECONDARY /
VOCATIONAL HIGH SCHOOL N/A

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

TRADE
COURSE
COLLEGE N/A

GRADUATE STUDIES N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUAR

BFP-QSF-HRMD-018 Rev. ØØ (05.04.18) CS FORM
 DATA SHEET
erience Sheet shall cause the filing of administrative/criminal case/s against the person

EFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Dual Citizenship

by naturalization

Pls. indicate country:

N/A
Street

Barangay

Province
2420

N/A
Street

Barangay

Province

N/A

09065943427 / 09507202927

DATE OF BIRTH (mm/dd/yyyy)

 (Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

N/A

N/A N/A

N/A N/A
parate sheet if necessary)
JANUARY 30,2019

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

(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

10/1/2018 PRESENT FIRE OFFICER III BUREAU OF FIRE PROTECTION P 32,114 '12-1''

8/4/2016 9/30/2018 FIRE OFFICER II BUREAU OF FIRE PROTECTION P 30,867 "12-1"

8/4/2016 12/31/2017 FIRE OFFICER I BUREAU OF FIRE PROTECTION P 16,934 "10-1"

3/18/2015 8/3/2016 FIRE OFFICER I BUREAU OF FIRE PROTECTION P 14,834 "10-0"

06/31/2012 3/17/2015 FIRE OFFICER I BUREAU OF FIRE PROTECTION P 14,834 "10-0"

6/1/2011 5/31/2012 FIRE OFFICER I BUREAU OF FIRE PROTECTION P 13,492 "10-0"

5/18/2011 5/31/2011 FIRE OFFICER I BUREAU OF FIRE PROTECTION P 12,150 "10-0"

1/17/2011 5/17/2011 FIRE OFFICER I FIRE NATIONAL TRAINING INSTITUTE P 12,150 "10-0"

7/1/2010 1/16/2011 FIRE OFFICER I BUREAU OF FIRE PROTECTION P 12,150 "10-0"

3/18/2010 6/30/2010 FIRE OFFICER I BUREAU OF FIRE PROTECTION P 10,808 "10-0"

 (Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 30,2019

BFP-QSF-HRMD-018 Rev. ØØ (05.04.18) CS FORM 212 (R

 LICENSE (if applicable)

NUMBER Date of
Validity

e on separate sheet if necessary)

of duties should be indicated in the attached Work Experience sheet. GOV'T

SERVICE

STATUS OF
APPOINTMENT

(Y/
N)
PERMANENT YES

PERMANENT YES

PERMANENT YES

PERMANENT YES

PERMANENT YES

PERMANENT YES

PERMANENT YES

TEMPORARY YES

TEMPORARY YES

TEMPORARY YES
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 / N
From To

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/ S
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To
 (Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

MEDALYA NG PAPURI (CY 2013,CY2015,CY2017, CY2018)

MEDALYA NG KASANAYAN ( CY 2017)

MEDALYA NG PAGTULONG SA NASALANTA ( CY 2016)

(Continue on separate sheet if necessary)

SIGNATURE DATE J
N
PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

N/A

arate sheet if necessary)

OGRAMS ATTENDED
ve (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)
arate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

N/A

arate sheet if necessary)

JANUARY 30,2019
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:
________________________________

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)

ID picture taken with
NAME ADDRESS TEL. NO. the last 6 months
3.5 cm. X 4.5 cm
(passport size)

With full and handwri

name tag and signature
printed name

Computer generate
or photocopied pictu
42. is not acceptable
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 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: BUREAU OF FIRE PROTECTION

ID/License/Passport No.:
Signature (Sign inside the box)
JANUARY 30,2019
Date/Place of Issuance:
Date Accomplished Right Thumbmark

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

Person Administering Oath

BFP-QSF-HRMD-018 Rev. ØØ (05.04.18) CS FORM 212 (Revised

 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