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 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 TELAN
NAME EXTENSION (JR., SR
FIRST NAME LUPO

MIDDLE NAME TAGAPAN

3. DATE OF BIRTH
(mm/dd/yyyy) 2/5/1957 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH ENRILE, CAGAYAN If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX ✘ Male Female

Single ✘ Married 17. RESIDENTIAL ADDRESS 2245 A

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. S
Saint Peter II Gulan
Other/s:
Subdivision/Village Ba
Lucena City Q
7. HEIGHT (m) 1.63 M.
City/Municipality Pr
8. WEIGHT (kg) 58 Kg. ZIP CODE 4301

18. PERMANENT ADDRESS 2245 A

9. BLOOD TYPE O
House/Block/Lot No. S
Saint Peter II Gulan
10. GSIS ID NO. 867C5LTT028
Subdivision/Village Ba
Lucena City
11. PAG-IBIG ID NO. 14600042342
City/Municipality Pr

12. PHILHEALTH NO. 08-000014847-4 ZIP CODE 4301

13. SSS NO. N/A 19. TELEPHONE NO. (042)710-3133

14. TIN NO. 138-326-513 20. MOBILE NO. 0921-233-2791

15. AGENCY EMPLOYEE NO. OSEC-DENRB-DMO4-93-2014 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME Telan 23. NAME of CHILDREN (Write full name and list all)
N/A Richard L. Telan
FIRST NAME Leonarda

MIDDLE NAME Lumactod Paul John L. Telan

OCCUPATION Government employee Julius Cesar L. Telan

EMPLOYER/BUSINESS NAME Community Environment and Natural Resources Office Jonathan L. Telan
x-x-x-x
BUSINESS ADDRESS Barangay, Talipan, Pagbilao, Quezon

TELEPHONE NO. (042) 710-2815

24. FATHER'S SURNAME Telan

Sr.
FIRST NAME Rosauro

MIDDLE NAME Palattao

25. MOTHER'S MAIDEN NAME Tagapan

SURNAME Telan

FIRST NAME Flordeliza

MIDDLE NAME Batumbacal (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 Divisoria Elementary School Primary Education 1964 1970 N/A

SECONDARY Lemu National High School High School 1970 1974 N/A
VOCATIONAL /

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

TRADE
COURSE
COLLEGE Please see separate sheet N/A N/A N/A N/A

GRADUATE STUDIES Please see separate sheet N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE April 18, 2017 CS FORM 212 (Re

L DATA SHEET
rience 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) N/A

Dual Citizenship

by naturalization

Pls. indicate country:

Argon
Street
Gulang-gulang
Barangay
Quezon
Province
4301

Argon
Street
Gulang-gulang
Barangay
Quezon
Province

(042)710-3133

0921-233-2791

[email protected]

DATE OF BIRTH (mm/dd/yyyy)

1/1/1981

3/7/1983

7/11/1985

9/20/1995

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

1970 First Honors

1974 N/A
 N/A N/A

N/A N/A

N/A N/A

parate 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 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

Forestry Technician Examination 86.3% 12/16/1979 Manila N/A

Forester Board Examination 75.15% 7/1/1980 Manila 01567

x-x-x

(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
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To (Y/
N)
Department of Environment and Natural
01/01/17 present Development Management Officer IV Php 52,783 22-1 Permanent Yes
Resouces, CALABARZON
Department of Environment and Natural
3/15/16 12/31/16 Development Management Officer IV Php 47,448 22-1 Permanent Yes
Resouces, CALABARZON
Department of Environment and Natural
6/17/15 3/15/16 Land Management Officer III Php32,397 18 Permanent Yes
Resouces, CALABARZON
Land Management Officer III/OIC CENR Department of Environment and Natural
08/16/13 6/16/15 Php 32,397 18 Permanent Yes
Officer Resouces, CALABARZON
Department of Environment and Natural
3/1/13 8/15/13 Land Management Officer III Php 32,397 18 Permanent Yes
Resouces, CALABARZON
Department of Environment and Natural
3/1/12 2/28/13 Land Management Officer III Php 29,458 18 Permanent Yes
Resouces, CALABARZON
Department of Environment and Natural
6/1/11 2/28/12 Land Management Officer III Php 29,058 18 Permanent Yes
Resouces, CALABARZON
Department of Environment and Natural
6/24/10 5/31/11 Land Management Officer III Php 26,091 18 Permanent Yes
Resouces, CALABARZON
Department of Environment and Natural
7/1/09 6/23/10 Land Management Officer III Php 23,115 18 Permanent Yes
Resouces, CALABARZON
Department of Environment and Natural
4/1/09 6/30/09 Land Management Officer III Php 20,138 18 Permanent Yes
Resouces, CALABARZON
Department of Environment and Natural
7/1/08 3/31/09 Land Managent Officer III Php 19647 18 Permanent Yes
Resouces, CALABARZON
Department of Environment and Natural
7/01/07 6/30/08 Land Management Officer III Php 17,861 18 Permanent Yes
Resouces, CALABARZON
Department of Environment and Natural
4/01/06 6/30/07 Land Management Officer III Php 16,237 18 Permanent Yes
Resouces, CALABARZON
Department of Environment and Natural
04/01/03 03/31/06 Land Management Officer III Php 15,841 18 Permanent Yes
Resouces, CALABARZON
Department of Environment and Natural
12/20/01 03/31/03 Forester II Php 15, 048 15 Permanent Yes
Resouces, CALABARZON
Department of Environment and Natural
01/01/01 12/19/01 Forester II Php 14,326 15 Permanent Yes
Resouces, CALABARZON
Department of Environment and Natural
01/01/20 12/31/20 Forester II Php 13,028 15 Permanent Yes
Resouces, CALABARZON
07/01/89 12/31/99 Sr. Forester Bureau of Forest Development Php 7,870 15 Permanent Yes

06/16/81 06/30/89 Forester I Bureau of Forest Development Php 855 11 Permanent Yes
Php
9/12/78 06/15/81 Forester Bureau of Forest Development 20.00/day
- Casual Yes

x-x-x

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

Society of Filipino Foresters 03/18/1981 present Member

Couples for Christ 06/01/1992 present Member

Saiint Jude Multipurpose Cooperative 10/05/1998 present Member

x-x-x-

(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/ CONDUCT
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To

1.LAWIN Forest and Biodiversity Protection System Training 07/05/2016 07/08/2016 '32 Technical
Department

2. Superviory Development Course (Track II) 08/25/2015 08/28/2015 '32 Supervisory

Civil Service C

3. Superviory Development Course (Track 1) 12/03/2014 12/05/2014 '24 Supervisory

4. Orientation Workshop for Newly Appointed LMOs,LMIs,LMEs and Action Planning on CY2016 Departmen
01/26/2016 01/28/2016 '24 Technical
Targets for Land Disposition Activities and GAD Mainstreaming Resources

5. Provincal Environmental Law and Enforcement Unit 01/28/2014 01/28/2014 '8 Technical
LGU Que
Departmen
6. Training of LMO and DPLI on Systematic Adjudication and Conflict Resolution 09/16/2011 09/16/2011 '8 Technical Resources
Departmen
7. Capability Building Seminar for Land Management Sector Personnel 04/21/2010 04/23/2010 '24 Technical Resources
8. Land Management and Admin Seminar with Component of Luzon Datum Familiarization and Departmen
02/25/2009 02/27/2009 '24 Technical
Survey Instrument Resources
Departmen
9. Capability Building Seminar for LMS Personnel under CARP 158 and PRS 92 02/12/2008 02/14/2008 '24 Technical Resources
Departmen
10. Global Positioning System Procedures, Processing and Adjustment 03/08/2006 03/09/2006 '24 Technical Resources

x-x-x

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIAT

31. SPECIAL SKILLS and HOBBIES 32.
(Write in full)
1. Forest Resources Management Letter of Commendation from EIIB, Region 1V Director, Lipa City Society o
2. Law and Preparaqtion of Legal Documents and
Certificate of recognition from the DENR Region 1V Regional Executive Director Couples
Conveyancing
3. Land Disposition, Administration and Sait Jude
Management Lucena C
4. Investigation of Land claims and Conflict Cases

(Continue on separate sheet if necessary)

SIGNATURE DATE
NMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

Member

Member

Member

on separate sheet if necessary)

NING PROGRAMS ATTENDED

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

CONDUCTED/ SPONSORED BY
(Write in full)

Department of Environment and Natural

Resources and USAID

Civil Service Commission

Civil Service Commission

Department of Environment and Natural
Resources R1VA

LGU Quezon Province

Department of Environment and Natural
Resources R1VA
Department of Environment and Natural
Resources R1VA
Department of Environment and Natural
Resources R1VA
Department of Environment and Natural
Resources R1VA
Department of Environment and Natural
Resources R1VA

on separate sheet if necessary)

MEMBERSHIP IN
ASSOCIATION/ORGANIZATION

(Write in full)
 Society of Filipino Foresters

Couples for Christ

Sait Jude Multipurpose Cooperative
Lucena City

on separate 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 ✘ 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 NO
YES ✘
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. Marlou P. Alutaya DENR-LMB, Binondo Manila 9287044140 3.5 cm. X 4.5 cm
(passport size)

Alfredo C. Palencia PENRO Office Lucena City 9198198536 With full and handwritten
name tag and signature over
DENR-Region III, San Fernando, printed name
Francisco E. Milla, Jr. Pampanga
9209533842
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: PASSPORT

ID/License/Passport No.: P0137232A

Signature (Sign inside the box)

Date/Place of Issuance: September 02,2016/DFA Lucena

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

 If YES, give details (country):

, affiant exhibiting his/her validly issued government ID as indicated above.

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