CS Form No.

212

PERSONAL DATA SHEET

Revised 2017

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 1. CS ID (Do not fill up. For CSC use
NOT ABBREVIATE. No. only)

I. PERSONAL INFORMATION
2. SURNAME MORENO
NAME EXTENSION (JR., SR)
FIRST NAME KAMHIL
MIDDLE NAME VERDEJO
3. DATE OF BIRTH
06-21-2001 16. CITIZENSHIP
Filipino Dual Citizenship
(mm/dd/yyyy)
by birth by naturalization
4. PLACE OF BIRTH GOA, CAM SUR If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female

6 CIVIL STATUS Single Married 17. RESIDENTIAL ZONE 5

ADDRESS
Widowed Separated House/Block/Lot Street
No.
Other/s:
SAN RAMON
Subdivision/Villa Barangay
ge
7. HEIGHT (m) 158 CM LAGONOY CAMARINES SUR
City/Municipality Province
8. WEIGHT (kg) 45 KG ZIP CODE

9. BLOOD TYPE
18. PERMANENT ZONE 5
ADDRESS
House/Block/Lot Street
No.
10. GSIS ID NO. SAN RAMON
Subdivision/Villa Barangay
ge
11. PAG-IBIG ID NO. LAGONOY CAMARINES SUR
City/Municipality Province
12. PHILHEALTH NO. ZIP CODE 4425
13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 650-777-787-00000 20. MOBILE NO. 09511405285

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

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS
NAME
BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME MORENO

NAME EXTENSION (JR., SR)
FIRST NAME MELCHOR
MIDDLE NAME CORUNO
25. MOTHER'S MAIDEN NAME CAROL SUMIDO VERDEJO
SURNAME MORENO
FIRST NAME CAROL
MIDDLE NAME VERDEJO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST
SCHOLARSH
26. PERIOD OF LEVEL/
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE YEAR IP/
LEVEL ATTENDANCE UNITS
(Write in full) (Write in full) GRADUATED ACADEMIC
From To EARNED
(if not HONORS
RECEIVED
SAN RAMON ELEMENTARY
ELEMENTARY SCHOOL
SAN RAMON PILOT NATIONAL
SECONDARY HIGH SCHOOL
VOCATIONAL /
TRADE COURSE
PARTIDO STATE UNIVERSITY BACHELOR OF SCIENCE IN
COLLEGE CRIMINOLOGY

GRADUATE STUDIES
(Continue on separate sheet if necessary)

SIGNATURE DATE
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) DATE OF LICENSE (if applicable)
RATING
UNDER SPECIAL LAWS/ CES/ CSEE EXAMINATI PLACE OF EXAMINATION / Date
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE ON / CONFERMENT of
CONFERME Validit
NT y
REGISTERED CRIMINOLOGIST 88.40 FEB 2-4, 2024 LEGAZPI CITY 0271183 06-21-
2027

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

05-06-24 PRESENT STATISTICAL RESEARCHER PHILIPPINE STATISTICS AUTHORITY COSW

(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 full) (mm/dd/yyyy) NUMBER OF POSITION / NATURE OF WORK
HOURS
From To
GRYPHON FIRE VOLUNTEER & RESCUE AUGUST PRESENT MEMBER
2023

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

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 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
authority, or to or office or to the person who has immediate supervision over
chief of bureau
you in the
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 YES NO

any court? 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 YES NO
modes: resignation, retirement, dropped from the rolls, dismissal, If YES, give details:
termination, end of term, finished contract or phased out (abolition) in the
38.
public
a. Haveoryou
private
eversector?
been a candidate in a national or local election held within YES NO
the last year (except Barangay election)? If YES, give details:
b. Have you resigned from the government service during the three (3)- YES NO
month period before the last election to promote/actively campaign for a If YES, give
national or local candidate? details:
39. Have you acquired the status of an immigrant or permanent resident of YES NO
another country?
If YES, give details (country):

40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for
Disabled Persons
a.
(RA 7277); and (c) Solo Parents Welfare Act of 2000 (RA 8972), please
Are you a member of any indigenous group? YES NO
answer the following
If YES, please
b. Are you a person with disability? specify:
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
(passport size)

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 or photocopied picture
true, correct and MORENO,
is notKAMHIL V.
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 PHOTO
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.
Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's
License, etc.)
PLEASE INDICATE ID Number and Date of
Government Issued ID: NATIONAL ID
Issuance
ID/License/Passport No.: 6125-0294-3086-9167
Signature (Sign inside the box)

Date/Place of Issuance: LAGONOY, CAM SUR

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