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 KUSAIN

FIRST NAME RYAN NAME EXTENSION (JR., SR)

MIDDLE NAME GANDAWALI

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
3/13/1994 ✘ by birth by naturalization
4. PLACE OF BIRTH KAYUPO BULUAN MAGUINDANAO If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS N/A N/A

Widowed Separated House/Block/Lot No. Street
KAYUPO PANDAG
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 5'9" PANDAG MAGUINDANAO
City/Municipality Province
8. WEIGHT (kg) 63 KLS. ZIP CODE 9633

9. BLOOD TYPE "B"

18. PERMANENT ADDRESS N/A N/A
House/Block/Lot No. Street
10. GSIS ID NO. N/A KAYUPO PANDAG
Subdivision/Village Barangay
11. PAG-IBIG ID NO. N/A PANDAG MAGUINDANAO
City/Municipality Province
12. PHILHEALTH NO. N/A ZIP CODE

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

14. TIN NO. N/A 20. MOBILE NO. 09532685475

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

II. FAMILY BACKGROUND

DATE OF BIRTH
22. SPOUSE'S SURNAME KUSAIN 23. NAME of CHILDREN (Write full name and list all)
(mm/dd/yyyy)
FIRST NAME URAYA NAME EXTENSION (JR., JAY-AR A. KUSAIN 8/24/2013
SR)
MIDDLE NAME ABUBACAR JAHER A. KUSAIN 9/1/2017

OCCUPATION STUDENT

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME KUSAIN

FIRST NAME THONG

MIDDLE NAME UTAP NAME EXTENSION (JR.,

SR)
25. MOTHER'S MAIDEN NAME

SURNAME GANDAWALI

FIRST NAME NORHAYA

MIDDLE NAME SELLA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGR
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 KAYUPO, BULUAN, MAGUINDANAO ELEMENTARY 2000 2006 GRADUATED 2006 DIPLOMA

SECONDARY /
VOCATIONAL CAMPO NATIONAL HIGH SCHOOL SECONDARY 2006 2012 GRADUATED 2012 DIPLOMA

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

TRADE
HADJI DATU SAIDONA PENDATUN
COURSE
COLLEGE DEGREE 2019 PRESENT N/A N/A N/A
FOUNDATION INC.

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

(Continue on separate sheet if necessary)

SIGNATURE DATE July 10, 2021

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

NONE NONE NONE NONE NONE NONE

(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)

2013 7/12/1905 SALES MAN TRADE MARKETING 14,300.00

(Continue on separate sheet if necessary)

SIGNATURE DATE June 17, 2021

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) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

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

(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)

DRIVING N/A N/A

COOKING

SINGING

(Continue on separate sheet if necessary)

SIGNATURE DATE JUNE 10, 2021

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
MOHAMADALI K. LIMBA KAYUPO, PANDAG, MAGUINDANAO 9069069122 3.5 cm. X 4.5 cm
(passport size)

NORODIN M. HADJIMONIB TUAL, PAGLAT, MAGUINDANAO 9262094856 With full and handwritten
name tag and signature over
printed name
CAREX M. AKIL RAMCOR, GEN. S.K. P., MAG. 93548543411
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: VOTERS I.D.

ID/License/Passport No.: VIN-0000-23RGK-0000-5

Signature (Sign inside the box)
JUNE 10, 2021
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 above.

Person Administering Oath

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