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 u

I. PERSONAL INFORMATION
2. SURNAME RAGONOT

FIRST NAME CARLITO JR

MIDDLE NAME ESTOYA

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 10/27/1986 ✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH Tacloban City, Leyte If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS 65-B Esperas Ave., Magallanes St.
Widowed Separated House/Block/Lot No. Street

Other/s: Brgy. 48-B

Subdivision/Village Barangay

7. HEIGHT (m) 1.8 Tacloban City Leyte

City/Municipality Province
8. WEIGHT (kg) 80 ZIP CODE 6500

9. BLOOD TYPE o
18. PERMANENT ADDRESS 65-B Esperas Ave., Magallanes St.
House/Block/Lot No. Street

10. GSIS ID NO. n/a Brgy. 48-B

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1211-1683-9595 Tacloban City Leyte

City/Municipality Province

12. PHILHEALTH NO. 13-200959261-3 ZIP CODE 6500

13. SSS NO. 06-2734672-3 19. TELEPHONE NO.

14. TIN NO. 415-093-581 20. MOBILE NO. 09069064684

15. AGENCY EMPLOYEE NO. n/a 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
NAME EXTENSION (JR., SR)
FIRST NAME 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 Ragonot

FIRST NAME Carlito Sr

MIDDLE NAME Garcia

25. MOTHER'S MAIDEN NAME

SURNAME Estoya

FIRST NAME Nimfa

MIDDLE NAME Teves (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY Rizal Central School Elementary June 1993 March 1999 graduated 1999

SECONDARY
VOCATIONAL / Leyte National High School Secondary June 1999 March 2003 graduated 2003

TRADE
COURSE
COLLEGE Eastern Visayas State University Tertiary June 2003 March 2007 graduated 2007

GRADUATE STUDIES Leyte Colleges Supplemental - BSED May 2016 October 2017 earned 18 units 2017
(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), P
L DATA SHEET
ence Sheet shall cause the filing of administrative/criminal case/s against the person concerned.

FORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

JR

by naturalization
Pls. indicate country:

Magallanes St.
Street
Brgy. 48-B
Barangay
Leyte
Province
6500
Magallanes St.
Street
Brgy. 48-B
Barangay
Leyte
Province

09069064684

[email protected]

DATE OF BIRTH (mm/dd/yyyy)

(Continue on separate sheet if necessary)

SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED
 SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED

graduated

graduated

graduated

earned 18
units
on separate sheet if necessary)

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

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ LICENSE (if applicable)
RATING DATE OF EXAMINATION /
CSEE BARANGAY ELIGIBILITY / DRIVER'S PLACE OF EXAMINATION / CONFERMENT
(If Applicable) CONFERMENT NUMBER Date of
LICENSE
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.
28. INCLUSIVE DATES (mm/dd/yyyy) POSITION TITLE SALARY/ JOB/ PAY GRADE (if GOV'T SERVICE
DEPARTMENT / AGENCY / OFFICE / COMPANY
(Write in full/Do MONTHLY SALARY applicable)& STEP (Format STATUS OF APPOINTMENT
(Write in full/Do not abbreviate) "00-0")/ INCREMENT (Y/ N)
not abbreviate)
From To

2009 2010 Office Staff Municipality of Giporlos P4,000.00 monthly salary Job Order Y

2013 2015 Office Staff E.W.T Corporation P9,000.00 monthly salary Contractual 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

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

On-the-Job Training 12/4/2006 1/12/2007 120 OJT Office of the Provincial Governor - Tacloban City

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

computer literate n/a Rising Youth Club (Brgy. 48-B Youth Organization)

good interpersonal skill

reading

singing

dancing

(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,

YES ✘ NO
a. within the third degree? YES ✘ NO
b. within the fourth degree (for Local Government Unit - Career Employees)?

If
YES
YES ✘ NO
,
35. a. Have you ever been found guilty of any administrative offense? give
detai
ls:If
YES YES
____
✘ NO
,
____
give
____
b. Have you been criminally charged before any court?
detai
____
ls:If
____
YES ____
YES
✘ NO
____
, Date Filed:
giveStatus of Case/s:
____
36. Have you ever been convicted of any crime or violation of any law, decree, ordinance✘or YES regulation ____
detaiNO
by any court or tribunal? ____
ls:
If YES, give details: ________________________________
____ ________________________________
____
YES ____
____ NO
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
out (abolition) in the public or private sector? ____
If YES, give details: Resignation in my previous employers
____
____
YES ✘ NO
38. a. Have you ever been a candidate in a national or local election held within the last year (except ____
____
Barangay election)? ____
____
____
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?
YES ____
____ ✘ NO
____
____
____
____
YES ✘ NO
____
If YES, give details:
____
39. Have you acquired the status of an immigrant or permanent resident of another country? ____
YES ✘ NO
____
40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA ____
YES ✘ NO
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:
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
(passport size)

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
 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
PHOTO
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.

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 No.:
Signature (Sign inside the box)

Date/Place of Issuance:
Date Accomplished Right Thumbmark

, affiant exhibiting his/her validly issued government ID as indicated above.

Person Administering Oath

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