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 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 APIAG
NAME EXTENSION (JR., SR)
FIRST NAME BRENDA MAY

MIDDLE NAME CONCHA

3. DATE OF BIRTH
5/26/1994
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by
by
naturalization
birth
4. PLACE OF BIRTH CATMON, CEBU If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS

House/Block/Lot No. Street
Widowed Separate
CALUMBOYAN
Other/s: d Subdivision/Village Barangay
SOGOD CEBU
7. HEIGHT (m) 1.25 M
City/Municipality Province
8. WEIGHT (kg) 55 KG ZIP CODE 6007
18. PERMANENT ADDRESS
9. BLOOD TYPE B+
House/Block/Lot No. Street
CALUMBOYAN
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121128189086 SOGOD CEBU

City/Municipality Province
12. PHILHEALTH NO. 12-025394774-3 ZIP CODE 6007

13. SSS NO. 06-3538159-2 19. TELEPHONE NO. (032) 239-5714

14. TIN NO. 750-236-942-000 20. MOBILE NO. 09169389211 / 09050886214

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME APIAG 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME CLENT EVAN BRIGGS XAVIER CONCHA APIAG 9/15/2017

MIDDLE NAME AUMAN

OCCUPATION SEAMAN

EMPLOYER/BUSINESS NAME BRIGHT MARITIME CORPORATION

BUSINESS ADDRESS
Maritime Plaza, 4th & 5th Floor, Cortada St, Ermita, Manila,
1000 Metro Manila
TELEPHONE NO. (02) 8835 6200

24. FATHER'S SURNAME CONCHA

NAME EXTENSION (JR., SR)
FIRST NAME ILDEBRANDO

MIDDLE NAME DALANON

25. MOTHER'S MAIDEN NAME SINGSON

SURNAME CONCHA

FIRST NAME SALVACION

MIDDLE NAME PADAYAO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

CATMON CENTRAL ELEMENTARY

ELEMENTARY
SCHOOL
ELEMENTARY EDUCATION 6/5/2000 3/31/2006 N/A 2006 N/A
GABRIEL JURADO FOUNDATION
SECONDARY
VOCATIONAL / SCHOOL INC.
SECONDARY EDUCATION 6/5/2006 3/31/2010 N/A 2010 N/A
CERTIFICATE IN INDUSTRIAL TECHNOLOGY-
CEBU TECHNOLOGICAL UNIVERSITY-
MAIN CAMPUS
FOOD PREPARATION AND SERVICES 6/7/2010 3/29/2012 N/A 2012 N/A
TECHNOLOGY
TRADE
CEBU TECHNOLOGICAL UNIVERSITY- BACHELOR OF SCIENCE IN INDUSTRIAL
COURSE
MAIN CAMPUS TECHNOLOGY-FOOD PREPARATION &
SERVICES TECHNOLOGY 6/11/2012 3/31/2014 N/A 2014 DEAN'S LIST 2012-2013

COLLEGE
CEBU TECHNOLOGICAL UNIVERSITY-
DANAO CAMPUS
DIPLOMA IN PROFESSIONAL EDUCATION 6/8/2015 3/29/2017 N/A 2017 N/A

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

LICENSURE EXAMINATION FOR TEACHERS 78.4 9/25/2016 CEBU CITY 1496393 5/26/2022

(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.
SALARY/ JOB/
28. INCLUSIVE DATES PAY GRADE (if
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY applicable)& STATUS OF GOV'T SERVICE
(Write in full/Do SALARY STEP (Format APPOINTMENT (Y/ N)
not abbreviate) (Write in full/Do not abbreviate) "00-0")/
From To INCREMENT

UP TO
1/7/2019
PRESENT
RURAL SANITATION INSPECTOR RURAL HEALTH UNIT, SOGOD CEBU 5000.00 N/A JOB ORDER Y
CROWN REGENCY HOTEL AND
09/15/2015 03/29/2016 COOK III 7000.00 N/A REGULAR N
TOWERS

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

CROWN REGENCY INSTITUTE OF TOURISM ON-THE-JOB TRAINING-FOOD AND BEVERAGE (SERVICE

5/7/2013 2/28/2014 1800.0
AND HOSPITALITY AND PRODUCTION) DEPARTMENT

(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
30. TITLE OF LEARNING AND DEVELOPMENT Type of LD
NUMBER OF CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS ( Managerial/ Supervisory/
(mm/dd/yyyy) HOURS
Technical/etc) (Write in full)
(Write in full) From To

COMMUNITY-BASED REHABILITATION PROGRAM 8/11/2019 11/17/2019 85.0 INTERVENTIONIST LOCAL GOVERNMENT UNIT

DEPARTMENT OF INFORMATION AND

EBPLS ON-PREMISE USER'S TRAINING AND DATA RURAL SANITATION
11/15/2019 11/17/2019 24.0 COMMUNICATION TECHNOLOGY-REGION
BUILD UP INSPECTOR
VII

TRAINING AND REFRESHER COURSE ON CODE OF RURAL SANITATION

4/2/2019 4/5/2019 32.0 DEPARTMENT OF HEALTH-REGION VII
SANITATION OF THE PHILIPPINES (PD 856) INSPECTOR

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 33.
(Write in full) (Write in
full)
BAKING COMMERCIAL COOKING NC II TESDA

COOKING COMMERCIAL COOKING NC II TESDA

COMPUTER LITERATE

TRACK AND FIELD DISTRICT MEET & PROVINCIAL MEET DEPED

FOOTBALL TRIANGULAR MEET CEBU TECHNOLOGICAL UNIVERSITY

(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 ✘ 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
YES ✘ NO
regulation 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 If YES, give details:
phased 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
YES ✘ NO
(except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
the last 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
a.
items:
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
3.5 cm. X 4.5 cm
DR. ARIEL C. ROQUE BAGATAYAM, SOGOD, CEBU 0917-1633-766 (passport size)

With full and handwritten

SHIELA MAE Y. DAGATAN DANAO CITY, CEBU 0932-4572-341 name tag and signature over
printed name
NOEL P. BURGOS LABANGON, CEBU CITY 0936-9045-621
Computer generated
42. or photocopied picture
I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and 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 PHOTO
filing of 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: PRC

ID/License/Passport No.: 1496393

Signature (Sign inside the box)

Date/Place of Issuance: CEBU CITY

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