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
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 ABBR
I. PERSONAL INFORMATION
2. SURNAME MATEO

FIRST NAME GJENERRICK CARLO

MIDDLE NAME DEL ROSARIO

3. DATE OF BIRTH
(mm/dd/yyyy) JUNE 30,1989 16. CITIZENSHIP

4. PLACE OF BIRTH MANILA If holder of dual citizenship,

please indicate the details.

5. SEX

6 CIVIL STATUS
17. RESIDENTIAL ADDRESS 2811-E
House/Block/Lot No.
N/A
Subdivision/Village
7. HEIGHT (m) 1.72 MANILA
City/Municipality
8. WEIGHT (kg) 70 ZIP CODE 1014

9. BLOOD TYPE O
18. PERMANENT ADDRESS 2811-E
House/Block/Lot No.
N/A
10. GSIS ID NO. N/A
Subdivision/Village

11. PAG-IBIG ID NO. 121157585660 MANILA

City/Municipality

12. PHILHEALTH NO. 0202-6606-6334 ZIP CODE 1014

13. SSS NO. 34-1018561-9 19. TELEPHONE NO. N/A

14. TIN NO. 477-611-497 20. MOBILE NO. 0915174450

15. AGENCY EMPLOYEE NO. 000-088-079-000 21. E-MAIL ADDRESS (if any) gjenerrick_mateo@roc
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all)

FIRST NAME NAME EXTENSION (JR., SR) SAMANTHA BRIDGETTE CAROL MATE
N/A
MIDDLE NAME

OCCUPATION
 EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME MATEO

FIRST NAME FEDERICO NAME EXTENSION

(JR., SR) N/A
MIDDLE NAME BALTAZAR

25. MOTHER'S MAIDEN NAME DEL ROSARIO

SURNAME MATEO

FIRST NAME RACHEL

MIDDLE NAME ALEGA (Continue on separate sheet

III. EDUCATIONAL BACKGROUND

26. NAME OF SCHOOL PERIOD OF ATTENDANCE

BASIC EDUCATION/DEGREE/COURSE
LEVEL (Write in
(Write in full)
full)
From

ELEMENTARY ANDRES BONIFACIO ELEMENTARY SCHOOL PRIMARY EDUCATION 1995

ARAULLO HIGH SCHOOL (ALTERNATIVE

SECONDARY /
VOCATIONAL LEARNING SYSTEM)
HIGH SCHOOL 2001

N/A N/A N/A

TRADE
COURSE
COLLEGE EMILIO AGUINALDO COLLEGE BACHELOR OF SCIENCE IN CRIMINOLOGY 2011

GRADUATE STUDIES N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE
HEET
the filing of administrative/criminal case/s against the person

THE PDS FORM.

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

NAME EXTENSION (JR., SR) N/A

Pls. indicate country:

2811-E SULU ST. STA CRUZ

House/Block/Lot No. Street
N/A 377 zone 38
Subdivision/Village Barangay
MANILA METRO MANILA
City/Municipality Province
1014
2811-E SULU ST. STA CRUZ
House/Block/Lot No. Street
N/A 377 zone 38
Subdivision/Village Barangay
METRO MANILA
City/Municipality Province

1014

N/A

09151744506

[email protected]

CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

NTHA BRIDGETTE CAROL MATEO 12/26/2012

 9/18/1962

1/25/1966

(Continue on separate sheet if necessary)

HIGHEST LEVEL/ SCHOLARSHIP/

PERIOD OF ATTENDANCE YEAR
UNITS ACADEMIC
GRADUATED
EARNED HONORS
(if not graduated) RECEIVED
To

2001 GRADUATED 2001 N/A

2006 GRADUATED 2006 N/A

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

CUM
2015 GRADUATED 2015
LAUDE

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

DATE January 16, 2018

CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable)
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

OCTOBER
BOARD OF CRIMINOLOGY 87.3 17,18,19, 2015
MANILA

PD 907 HONOR GRADUATE ELIGIBILITY GRANTED 3/28/2015 MANILA

(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 shee
28. INCLUSIVE DATES
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY
(Write in full/Do not (Write in SALARY
abbreviate) full/Do not abbreviate)
From To

2/1/2017 PRESENT POLICE OFFICER 1 PHILIPPINE NATIONAL POLICE

EMILIO AGUINALDO COLLEGE SCHOOL

11/3/2015 5/30/2016 INSTRUCTOR 1 PHP 16000
OF CRIMINOLOGY
 (Continue on separate sheet if necessary)

SIGNATURE DATE January 16, 2018

CS FORM
 LICENSE (if applicable)
NATION / CONFERMENT
NUMBER Date of
Validity

ANILA 0122810 6/30/2019

10011315134
ANILA 12/15/2015
3

ttached Work Experience sheet. GOV'T

SERVICE
SALARY/ JOB/ PAY
GRADE (if
STATUS OF
applicable)& STEP
(Format "00-0")/ APPOINTMENT
INCREMENT
(Y/
PHP TEMPOR
N)
SG 10 YES
29,668.00 ARY

CONTRACTU
N/A NO
AL
January 16, 2018
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

From To

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
ATTENDANCE
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy)
From To

PUBLIC SAFETY FIELD TRAINING PROGRAM 9/15/2017 PRESENT N/A

PUBLIC SAFETY BASIC RECRUIT COURSE 2/1/2017 8/11/2017 1440

 (Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32.
(Write in full)

BASKETBALL N/A

COMPUTER LITERATE

(Continue on separate sheet if necessary)

SIGNATURE DATE
NTARY ORGANIZATION/S

POSITION / NATURE OF WORK

ED
Chief/Executive/Managerial positions)

Type of LD
( Managerial/ CONDUCTED/ SPONSORED BY
Supervisory/ (Write in full)
Technical/etc)

MANDATORY MANILA POLICE DISTRICT (MPD)

MANDATORYNATIONAL CAPITAL REGION TRAINING CENTER

 MEMBERSHIP IN ASSOCIATION/ORGANIZATION
33. (Write
in full)

N/A

DATE January 16, 2018

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
a.
8972), please answer the following items:
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.

JESSE PABUNAN TAGUIG CITY 9959883392

 UNIT 10 7TH FLOOR ANGELINA
ALISA CAMILLE RANILE BAUTISTA BLDG. LACSON ST MANILA
9957314490

UNIT 10 7TH FLOOR ANGELINA

SANDY RANILE BLDG. LACSON ST MANILA
9174351314
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 misrepresentation made in this document and its attachments shall cause the filing of administrative/criminal case/s against me.

42.

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

PLEASE INDICATE ID Number and Date of
Issuance
Government Issued ID: PNP ID
ID/License/Passport No.: 17E040350
Signature (Sign inside the box)
January 16, 2018
Date/Place of Issuance: 5/29/17 CAMP CRAME Q.C Date Accomplished

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

S, give details:
__________________________
__________________________

S, give details:
__________________________
__________________________

S, give details:
__________________________
__________________________

S, give details:
__________________________
__________________________

S, give details:
__________________________
__________________________

S, give details (country):

please specify ID No:

please specify ID 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
or photocopied picture
is not acceptable
 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
or photocopied picture
is not acceptable

PHOTO

Right Thumbmark

r validly issued government ID as indicated above.

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