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 EWAG
NAME EXTENSION (JR., SR) N/A
FIRST NAME LANIE GRACE

MIDDLE NAME AMBONG

3. DATE OF BIRTH
(mm/dd/yyyy) 10/23/1997 16. CITIZENSHIP

4. PLACE OF BIRTH SAN PEDRO, LAGUNA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX

6 CIVIL STATUS
17. RESIDENTIAL ADDRESS 740 D MAGINHAWA
House/Block/Lot No. Street
N/A SAN ANTONIO
Subdivision/Village Barangay

7. HEIGHT (m) 157 CITY OF SAN PEDRO LAGUNA

City/Municipality Province
8. WEIGHT (kg) 43 ZIP CODE 0423

9. BLOOD TYPE A+ 18. PERMANENT ADDRESS 740 D MAGINHAWA

House/Block/Lot No. Street

10. GSIS ID NO. N/A N/A SAN ANTONIO

Subdivision/Village Barangay

11. PAG-IBIG ID NO.

CITY OF SAN PEDRO LAGUNA
City/Municipality Province

12. PHILHEALTH NO. 172524406190 ZIP CODE 4023

13. SSS NO. 3515946520 19. TELEPHONE NO. N/A

14. TIN NO. 336-486-277 20. MOBILE NO. 09919059945

15. AGENCY EMPLOYEE NO. 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)

FIRST NAME N/A

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

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME EWAG

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

MIDDLE NAME TAYAO

25. MOTHER'S MAIDEN NAME

SURNAME EWAG

FIRST NAME MARILYN

MIDDLE NAME AMBONG (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY KINUSKUSAN ELEMENTARY SCHOO PRIMARY EDUCATION 2003 2011 N/A N/A N/A

SECONDARY MT.CARMEL DEVELOPMENT ACADEMY HIGH SCHOOL 2011 2013 N/A N/A N/A
VOCATIONAL /

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

TRADE
COURSE
COLLEGE GOLDEN STATE COLLEGE BECEd 2018 2018 N/A N/A N/A

GRADUATE STUDIES N/A ALTERNATIVE LEARNING SYSTEM 2013 2013 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. 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

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

(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)

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

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

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

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

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

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

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

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

(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
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

N/A

N/A

(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)

N/A N/A N/A

(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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
________________________________

35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
________________________________

b. Have you been criminally charged before 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, 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: resignation,
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
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before 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?
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?
If YES, please specify:
b. Are you a person with disability?
If YES, please specify ID No:
c. Are you a solo parent?
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
CEDRIX BUENAOBRA SAN VICENTE, LAGUNA 09914667354 (passport size)

TERESITA OQUINDO CUYAB SAN PEDRO LAGUNA 9127239613 With full and handwritten
name tag and signature over
printed name

42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and Computer generated
or photocopied picture
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable
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: NATIONAL ID

ID/License/Passport No.: 4708631824621671

Signature (Sign inside the box)

Date/Place of Issuance: GENERAL SANTOS 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