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 JACLA
NAME EXTENSION (JR., SR)
FIRST NAME LIBERTY

MIDDLE NAME BUNGAY

3. DATE OF BIRTH
(mm/dd/yyyy) 11/6/1991 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH CITY OF SAN FERNANDO, LA UNION If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS

Widowed House/Block/Lot No. Street
Separated PUROK 4 SEVILLA NORTE
Other/s:
Subdivision/Village Barangay
CITY OF SAN FERNANDO LA UNION
7. HEIGHT (m) 1.55
City/Municipality Province
8. WEIGHT (kg) 48 ZIP CODE 2500

18. PERMANENT ADDRESS

9. BLOOD TYPE
House/Block/Lot No. Street
PUROK 4 SEVILLA NORTE
10. GSIS ID NO.
Subdivision/Village Barangay
CITY OF SAN FERNANDO LA UNION
11. PAG-IBIG ID NO. 121021298932
City/Municipality Province

12. PHILHEALTH NO. 050253139959 ZIP CODE 2500

13. SSS NO. 0121561305 19. TELEPHONE NO. N/A

14. TIN NO. 417947400 20. MOBILE NO. 9480360836

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME JACLA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME KARL JUMA KHAEL ANGELO ZHEUS B. JACLA 10/22/2016

MIDDLE NAME MAMAUAG

OCCUPATION CIVIL ENGINEER

EMPLOYER/BUSINESS NAME DSWD (KALAHI CIDSS)

BUSINESS ADDRESS CITY OF SAN FERNANDO, LA UNION

TELEPHONE NO. N/A

24. FATHER'S SURNAME BUNGAY

NAME EXTENSION (JR., SR)
FIRST NAME VIRGILIO

MIDDLE NAME DULAY

25. MOTHER'S MAIDEN NAME

SURNAME COSTALES

FIRST NAME AGRIPINA

MIDDLE NAME MUNAR (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY SEVILLA COMMUNITY SCHOOL ELEMENTARY 1998 2004 N/A 2004 2ND HONOR (1-6)

SECONDARY
VOCATIONAL / DMMMSU-MLUC SECONDARY 2004 2008 N/A 2008 TOP 10

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

TRADE
DEANS LISTER (2ND-
COURSE
COLLEGE SAINT LOUIS COLLEGE COLLEGE 2008 2012 N/A 2012 4TH YR)

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

(Continue on separate sheet if necessary)

SIGNATURE DATE
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

Civil Service Professional 83.49% 12/8/2018 Saint Louis College/ City of San Fernando 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
28. INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
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)

05/25/2015 03/14/2017 Branch Cashier PNB General Insurers Co., Inc 13,000.00 Regular N

03/17/2014 01/21/2015 Client Service Associate BDO Unibank, Inc. 12,500.00 Regular N

04/16/2012 7/3/2014 Sales-in-Charge RUSI Motors, Luzon Ram Cycle Inc. 10,000.00 Regular N

(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 / 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

Central Banking System Forum 1/3/2011 1/3/2011 8.0 Bangko Sentral ng Pilipinas Reg.1

(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 in
(Write in full)
full)

Computer literate N/A N/A

Able to communicate well N/A N/A

Fast learner N/A N/A

Service-oriented N/A N/A

Highly motivated N/A N/A

Cheerful and hardworking N/A N/A

(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 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 ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘

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? Resignation
________________________________
________________________________
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
MS. EISHEIL A. ADLAWAN CITY OF SAN FERNANDO, LA UNION 09164025302 3.5 cm. X 4.5 cm
(passport size)

MS. KRISHA LIZELLE T. ALCANTARA CITY OF SAN FERNANDO, LA UNION 09174106376 With full and handwritten
name tag and signature over
printed name
MS. EVALYN C. GOLOSINO NAGA CITY, CAMARINES SUR 09099165837
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: Unified Multi-Purpose ID

ID/License/Passport No.: 0111-2354855-8

Signature (Sign inside the box)

Date/Place of Issuance: City of San Fernando, La Union

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