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
I. PERSONAL INFORMATION
2. SURNAME SALDAJENO
NAME EXTENSION (JR., SR)
FIRST NAME JOSE GONZALO
MIDDLE NAME
DATE OF BIRTH ROBLES
3. (mm/dd/yyyy) DATE OF
16. CITIZENSHIP
BIRTH
(mm/dd/yyyy) 2/16/1990
4. PLACE OF BIRTH BACOLOD CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX

17. RESIDENTIAL ADDRES #416 NEPTUNE STREET

6 CIVIL STATUS
House/Block/Lot No. Street
PUENTEBELLA SUBD. TACULING
Subdivision/Village Barangay
Bacolod City NIR
7. HEIGHT (m) 5'7
City/Municipality Province
8. WEIGHT (kg) 300 lbs. ZIP CODE

18. PERMANENT ADDRESS #416 NEPTUNE STREET

9. BLOOD TYPE B
House/Block/Lot No. Street
PUENTEBELLA SUBD. TACULING
10. GSIS ID NO. N/A
Subdivision/Village Barangay
Bacolod City
11. PAG-IBIG ID NO. N/A
City/Municipality Province
12. PHILHEALTH NO. 11-025278818-2 ZIP CODE 6100

13. SSS NO. N/A 19. TELEPHONE NO. 4348302

14. TIN NO. 336-885-922 20. MOBILE NO. 09499425571

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)
NAME EXTENSION (JR., SR) N/A
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 SALDAJENO
JR.
FIRST NAME JOSE
MIDDLE NAME OBANI
25. MOTHER'S MAIDEN NAME
 SURNAME ROBLES
FIRST NAME ARTESANO
MIDDLE NAME SALLY (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE PERIOD OF LEVEL/
26. ATTENDANCE UNITS
LEVEL (Write EARNED
(Write in full) in full) (if not
From To graduated)

ELEMENTARY UNIVERSITY OF ST.LASALLE INTEGRATED SCHOOL 1997 2004

UNIVERSITY OF ST.LASALLE INTEGRATED

SECONDARY
VOCATIONAL / SCHOOL
2004 2008

NONE NONE

TRADE COURSE UNIVERSITY OF NEGROS OCCIDENTAL BACHELOR O SCIENCE IN CIVIL

RECOLLETOS ENGINEERING
2009 2014

COLLEGE
BACHELOR OF SCIENCE IN BUSINESS
UNIVERSITY OF ST.LASALLE ADMNINISTRATION MAJOR IN 2014 2017
MARKETING MANAGEMENT

GRADUATE STUDIES NONE NONE

(Continue on separate sheet if necessary)
SIGNATURE DATE
CS FORM 212 (Revised 2017), Page
filing of administrative/criminal

HE PDS FORM.
(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Pls. indicate country:

NEPTUNE STREET

Street
TACULING
Barangay
NIR
Province

NEPTUNE STREET
Street
TACULING
Barangay
NIR
Province

4348302

[email protected]
DATE OF BIRTH
(mm/dd/yyyy)
parate sheet if necessary)

SCHOLARSHIP
YEAR
/ ACADEMIC
GRADUAT
HONORS
ED
RECEIVED

2004

2008

NOT GRADUATED

2017

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

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) LICENSE (if applicable)
DATE OF
UNDER SPECIAL LAWS/ CES/ CSEE RATING
EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY / (If Applicable) NUMBER
CONFERMENT
DRIVER'S LICENSE

CAREER SERVICE PROFESSIONAL 80.61% 08/21/2012 BACOLOD CITY 08-218131

CAREER SERVICE SUB-PROFESSIONAL 81.77% 05/27/2012 BACOLOD CITY 08-213696

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

BACOLOD CITY NATIONAL HIGH

JOB ORDER EMPLOYEE 6'500
SCHOOL
 (Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 2 of 4
 LICENSE (if applicable)

Date of
Validity
12/06/201
2
07/03/201
2

Experience sheet. GOV'T

SERVICE

(Y/ N)
RM 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 NUMBER OF
(Write in full) HOURS POSITION / NATURE OF WORK
(mm/dd/yyyy)
From To

SOCIAL SECURITY SYSTEM 04/04/2016 06/13/2016 400.0 DATA ENCODER

(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 NUMBER OF ( Managerial/ CONDUCTED/ SPONSORED BY
PROGRAMS (Write in full) (mm/dd/yyyy)
HOURS Supervisory/ (Wri
Technical/etc)
From To

AUTOMOTIVE DRIVING 08/10/2013 12/13/2013 300 ALTERNATIVE LEARNING S

 (Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
MEMBERSHIP
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATI
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)
in full)

BOXING MARKETERS UN

DRAWING/SKETCHING

PLAYING DRUMS

WATCHING MOVIES

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 20
GANIZATION/S

POSITION / NATURE OF WORK

DATA ENCODER

Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

ALTERNATIVE LEARNING SYSTEM (ALS)

 MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(Write
in full)

MARKETERS UNION

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, If YES, give details:
finished contract or phased 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 If YES, give details:
candidate?
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
a.
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.
ID picture taken within
JAN IVAN Y. MISAGAL COA-DEPED (034)4347266 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)
AIDA A. LEGISLADOR COA-DAR (034)4338130
With full and handwritten
name tag and signature over
printed name
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.
Computer generated
or photocopied picture
is not acceptable

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:

ID/License/Passport No.
Signature (Sign inside the box)

Date/Place of Issuance
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

e details:
_____________________
_____________________

e details:
_____________________
_____________________

e details:
_____________________
_____________________

e details:
_____________________

e details:
_____________________
_____________________

e details (country):

specify ID No:

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

alidly issued government ID as indicated above.

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