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 REYES
NAME EXTENSION (JR., SR) N/A
FIRST NAME KIMBERLY ALTHEA GLEE

MIDDLE NAME BASILIO

3. DATE OF BIRTH
(mm/dd/yyyy) 11/2/1998 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH LAOAG CITY, ILOCOS NORTE If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS #313

Widowed House/Block/Lot No. Street

Separate
d JUAN
Other/s:
Subdivision/Village Barangay
SOLSONA ILOCOS NORTE
7. HEIGHT (m) 1.55m
City/Municipality Province
8. WEIGHT (kg) 61 kgs ZIP CODE 2910

18. PERMANENT ADDRESS #313

9. BLOOD TYPE O
House/Block/Lot No. Street
JUAN
10. GSIS ID NO. N/A
Subdivision/Village Barangay
SOLSONA ILOCOS NORTE
11. PAG-IBIG ID NO. 1212 5716 2510
City/Municipality Province

12. PHILHEALTH NO. 05-025751898-9 ZIP CODE 2910

13. SSS NO. 01-2825446-6 19. TELEPHONE NO. N/A

14. TIN NO. 7314308180000 20. MOBILE NO. 0906-885-2984 / 0919-613-2262

15. AGENCY EMPLOYEE NO. R20111 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)
FIRST NAME N/A N/A N/A

MIDDLE NAME N/A N/A N/A

OCCUPATION N/A N/A N/A

EMPLOYER/BUSINESS NAME N/A N/A N/A

BUSINESS ADDRESS N/A N/A N/A

TELEPHONE NO. N/A N/A N/A

24. FATHER'S SURNAME REYES

NAME EXTENSION (JR., SR) N/A
FIRST NAME EDISON

MIDDLE NAME MALASIG

25. MOTHER'S MAIDEN NAME

SURNAME BASILIO

FIRST NAME NELIA

MIDDLE NAME DOROPAN (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY SAN MARCELINO ELEMENTARY SCHOOL PRIMARY 2004 2010 GRADUATED 2010 WITH HONORS

SECONDARY SOLSONA NATIONAL HIGH SCHOOL SECONDARY 2010 2014 GRADUATED 2014 N/A
 VOCATIONAL /

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

TRADE
COURSE
COLLEGE MARIANO MARCOS STATE UNIVERSITY BACHELOR OF SECONDARY EDUCATION 2014 2018 GRADUATED 2018 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 October 7, 2024

BFP-QSF-HRMD-018 Rev. ØØ (05.04.18) CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY
27. LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER RATING DATE OF
SPECIAL LAWS/ CES/ CSEE (If Applicable) EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT NUMBER Date of
Validity
BOARD LICENSURE EXAMINATION FOR PROFESSIONAL 82.80% 09/30/2018 LAOAG CITY, ILOCOS NORTE 1692465 11/2/2027
TEACHER ( RA 1080)

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

1/10/2020 PRESENT FIRE OFFICER 1 BUREAU OF FIRE PROTECTION P 29,668.00 SG10 PERMANENT Y

4/8/2019 1/6/2020 COLLEGE INSTRUCTOR NORTHERN CHRISTIAN COLLEGE P6,000.00 N/A PART-TIME N

(Continue on separate sheet if necessary)

SIGNATURE DATE October 7, 2024
BFP-QSF-HRMD-018 Rev. ØØ (05.04.18) 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
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE Type of LD
NUMBER OF HOURS
( Managerial/ CONDUCTED/ SPONSORED BY
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

NC III (DRIVING) TECHNICAL

TECHNICAL EDUCATION AND SKILLS
DEVELOPMENT AUTHORITY

FIRE BASIC TRAINING COURSE 11/8/2022 12/16/2022 640 MANDATORY NATIONAL FIRE TRAINING INSTITUTE

FIRE RECRUIT ORIENTATION COURSE 1/10/2020 11/17/2020 TECHNICAL BFP REGIONAL OFFICE 1

NC II (DRIVING) 10/21/2018 11/16/2018 1680.0 TECHNICAL

TECHNICAL EDUCATION AND SKILLS
DEVELOPMENT AUTHORITY

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

COMPUTER LITERATE N/A BIOLOGY TEACHERS ASSOCIATION OF THE

PHILIPPINES

TEACHING

PLAYING INSTRUMENT

(Continue on separate sheet if necessary)

SIGNATURE DATE October 7, 2024

BFP-QSF-HRMD-018 Rev. ØØ (05.04.18) 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 by any court or tribunal? YES ✘ NO
If YES, give details:
________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation,
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased YES ✘ NO
out (abolition) in the public or private sector? If YES, give details:
________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? YES ✘ NO
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the YES ✘ NO
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 items:
a. Are you a member of any indigenous group?
✘ YES NO
If YES, please specify: ISNAG
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.

SUPT BONIFACIO C SACATRAPOS JR PAOAY, ILOCOS NORTE 09176795500 ID picture taken within
the last 6 months
3.5 cm. X 4.5 cm
(passport size)
CINSP ARNEL B RATUITA PASUQUIN, ILOCOS NORTE 09384564740
With full and handwritten
name tag and signature over
printed name
INSP RODOLFO O CASTILLO LUNA, LA UNION 09184919715
Computer generated
or photocopied picture
42. 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 filing of
administrative/criminal case/s against me. PHOTO

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of Issuance

Government Issued ID: BFP ID

ID/License/Passport No.: R20111

Signature (Sign inside the box)
12/28/2018 October 7, 2024
Date/Place of Issuance: SAN NICOLAS, ILOCOS NORTE 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

BFP-QSF-HRMD-018 Rev. ØØ (05.04.18) CS FORM 212 (Revised 2017), Page 4 of 4