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 AB1. CS ID No (Do not fill up. For CSC use only)

I. PERSONAL INFORMATION
2. SURNAME Gustilo
NAME EXTENSION (JR., SR)
FIRST NAME Juhanna Lizl

MIDDLE NAME Sabas

3. DATE OF BIRTH
(mm/dd/yyyy)
9/21/1990 16. CITIZENSHIP Filipino Dual Citizenship
by birth by naturalization

4. PLACE OF BIRTH Cebu City If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female P hilippines

Single Married 17. RESIDENTIAL ADDRES Blk.10 lot 4

6 CIVIL STATUS Suba Masulog
Widowed Separated House/Block/Lot No.
Genesis Subdivision
Basak
Other/s:
Subdivision/Village Barangay
Lapu- Lapu City Cebu
7. HEIGHT (m) 5'0
City/Municipality Province
8. WEIGHT (kg) 55kg. ZIP CODE 6015

18. PERMANENT ADDRESS Blk.10 lot 4 Suba Masulog

9. BLOOD TYPE "O"
House/Block/Lot No. Street
Genesis Subdivision Basak
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121295018185 Lapu-Lapu City Cebu

City/Municipality Province

12. PHILHEALTH NO. 12-050925808-8 ZIP CODE 6015

13. SSS NO. 35-1688599-4 19. TELEPHONE NO. N/A

14. TIN NO. 298-500-490-000 20. MOBILE NO. 09351477715/09056819757

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if an [email protected]
II. FAMILY BACKGROUND
DATE OF BIRTH
22. SPOUSE'S SURNAME Gustilo 23. NAME of CHILDREN (Write full name and list all)
(mm/dd/yyyy)
FIRST NAME Romeo lll Angel Rojhan Gustilo 11/27/2011
MIDDLE NAME Bagares
OCCUPATION N/A
EMPLOYER/BUSINESS NAM N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24.FATHER'S SURNAME Sabas
Jr.
FIRST NAME Agapito
MIDDLE NAME Albarida
25. MOTHER'S MAIDEN NAME

SURNAME Membreve
FIRST NAME Ma. Liza
MIDDLE NAME Terol (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY Zapatera Elem. School Primary Education 6/19/1905 6/25/1905 Graduated 2003 N/A

SECONDARY Abellana National High School High School 6/25/1905 6/29/1905 Graduated 2007 N/A

VOCATIONAL / Department of Manpower Development Outstandin

TRADE COURSE
Housekeeping NCll June Sept. Graduated 2017
and Placement g Trainee
Bachelor of Elementary Education in
COLLEGE Cebu Eastern College 7/9/1905 7/14/1905 Graduated 2022 3rd Honors
General Education

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 31, 2023

CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) DATE OF LICENSE (if applicable)
RATING
UNDER SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity

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

(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. NUMBER OF
(Write in full) (mm/dd/yyyy) POSITION / NATURE OF WORK
HOURS
From To

(Continue on separate sheet if necessary)

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

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33. ASSOCIATION/ORGANIZATION
(Write in full)
(Write in full)

(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
chief of bureau or office or to the person who has immediate supervision over you
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, YES NO
ordinance or 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: YES NO
resignation, retirement, dropped from the rolls, dismissal, termination, end of term, If YES, give details:
finished contract or 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 YES NO
year (except Barangay election)? If YES, give details:
b. Have you resigned from the government service during the three (3)-month YES NO
period before the last election to promote/actively campaign for a national or local If YES, give details:
candidate?
39. Have you acquired the status of an immigrant or permanent resident of another YES NO
country?
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
a answer
Are you the following
a member ofitems:
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
4.5 cm. X 3.5 cm
(passport size)

Computer generated
or photocopied picture
is not acceptable
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a
true, correct and 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 PHOTO
misrepresentation made in this document and its attachments shall cause the 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

ID/License/Passport N
Signature (Sign inside the box)

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 a

Person Administering Oath

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