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 BENITEZ
NAME EXTENSION (JR., SR)
FIRST NAME BLESS JOSE'F

MIDDLE NAME BARRIDO

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 01/10/95 ✘ Filipino Dual Citizenship
✘
by by
4. PLACE OF BIRTH ILOILO CITY If holder of dual citizenship, birth
Pls. naturalization
indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS PROJECT 4

House/Block/Lot No. Street
Separate
Widowed BRGY. SOOC, AREVALO
Other/s: d Subdivision/Village Barangay
7. HEIGHT (m) 1.65 ILOILO CITY ILOILO
City/Municipality Province
8. WEIGHT (kg) 67 ZIP CODE

9. BLOOD TYPE O
18. PERMANENT ADDRESS PROJECT 4
House/Block/Lot No. Street

10. GSIS ID NO. N/A BRGY. SOOC, AREVALO

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121116092596 ILOILO CITY ILOILO

City/Municipality Province

12. PHILHEALTH NO. 11-050660291-2 ZIP CODE 5000

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

14. TIN NO. 451-169-962 20. MOBILE NO. 09275685180

15. AGENCY EMPLOYEE NO. 20181100162 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) N/A
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME BENITEZ

NAME EXTENSION (JR., SR) JR
FIRST NAME ELEUTERIO
MIDDLE NAME CALDEA
25. MOTHER'S MAIDEN NAME

SURNAME BARRIDO
FIRST NAME ALIFTY
MIDDLE NAME BASISTO (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
HONORS
(Write in full) EARNED
full) (if not graduated) RECEIVED
From To

ELEMENTARY LUCA ELEMENTARY SCHOOL Elementary 2002 2008 Graduated 2008 Salutatorian

VOCATIONAL
SECONDARY / ILOILO CITY NATIONAL HIGH SCHOOL High School 2008 2012 Graduated 2012 with Honors

N/A N/A
TRADE
COLLEGE
COURSE WEST VISAYAS STATE UNIVERSITY Bachelor of Arts in Political Science 2012 2016 Graduated 2016 cum laude

University
GRADUATE STUDIES CENTRAL PHILIPPINE UNIVERSITY Juris Doctor 2nd year 2018
Scholar
(Continue on separate sheet if necessary)

SIGNATURE DATE September 25, 2019

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

PD 907(HONOR GRADUATE ELIGIBILITY) 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
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)

10/8/2018 Present PATROLMAN Philippine National Police - PRO 6 P 29,668 10 Temporary Yes

(Continue on separate sheet if necessary)

SIGNATURE DATE September 25, 2019

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

POLITICAL SCIENCE STUDENT'S ORGANIZATION, INC. 6/10/2012 4/1/2016 ASSISTANT SECRETARY GENERAL

ROTARACT CLUB OF ILOILO 6/24/2013 4/1/2016 VOLUNTEER

(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

PUBLIC SAFETY BASIC RECRUIT COURSE CLASS 2018-01 OCT. 15, 2018 APR. 17, 19 960 MANDATORY PHILIPPINE PUBLIC SAFETY COLLEGE

(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)

(Continue on separate sheet if necessary)

SIGNATURE DATE September 25, 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)

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
DR. APRIL DREAM G. RICO BRGY. SAMBAG, JARO, ILOILO CITY 09992776108 3.5 cm. X 4.5 cm
(passport size)

PMAJ HERMAN CELIZ PAVIA, ILOILO 09186771508 With full and handwritten
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 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: TIN

ID/License/Passport No.: 451-169-962

Signature (Sign inside the box)
September 25, 2019
Date/Place of Issuance: APRIL 30, 2014
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this October 8, 2019 , affiant exhibiting his/her validly issued government ID as indicated above.

PMAJ JOVIL M. SEDEL

CHIEF OF POLICE- BCPS 1
Person Administering Oath

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