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 use only)

I. PERSONAL INFORMATION
2. SURNAME DELA CRUZ

FIRST NAME EDUARDO NAME EXTENSION (JR., SR) JR

MIDDLE NAME BUYUGAN

3. DATE OF BIRTH
(mm/dd/yyyy) 11/19/1985 16. CITIZENSHIP ✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH BRGY., RANCHO BASSIT ANGADANAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS

Widowed Separated House/Block/Lot No. Street

MARABULIG 1
Other/s:
Subdivision/Village Barangay
CAUAYAN CITY Isabela
7. HEIGHT (m) 1.85
City/Municipality Province
8. WEIGHT (kg) 97 ZIP CODE 3300

18. PERMANENT ADDRESS

9. BLOOD TYPE "B+"
House/Block/Lot No. Street
MARABULIG 1
10. GSIS ID NO.
Subdivision/Village Barangay

11. PAG-IBIG ID NO.

CAUAYAN CITY Isabela
City/Municipality Province

12. PHILHEALTH NO. ZIP CODE 3305

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

14. TIN NO. 448-443-366 20. MOBILE NO. 09266380251

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME DELA CRUZ 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME ZANDER JAMES G. DELA CRUZ 8/24/2011

MARICON
MIDDLE NAME DAVID JAY G. DELA CRUZ 9/14/2015
GUIANG
OCCUPATION ADMINISTRATIVE ASSISTANT

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME DELA CRUZ

FIRST NAME EDUARDO NAME EXTENSION (JR., SR) SR.

MIDDLE NAME CRUZADA

25. MOTHER'S MAIDEN NAME

SURNAME BUYUGAN

FIRST NAME IMELDA

MIDDLE NAME MANAGUELDO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY ALICIA SOUTH CENTRAL SCHOOL ELEMENTARY 1991 1997

SECONDARY
VOCATIONAL / SCHOOL OF OUR LADY OF ATOCHA HIGH SCHOOL 1997 2004

N/A

TRADE
COURSE
COLLEGE ISABELA STATE UNIVERSITY BACHELOR OF SCIENCE IN CRIMINOLOGY 2006 2008

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (if applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
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
SERVICE
28. INCLUSIVE DATES SALARY/ JOB/ PAY
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)
05/18/2010 Oct-10 PRESERVE DEPT. NEWTON FOOD INCORPORATION 16,000.00 N/A CONTRACTUAL N

11/22/2010 04/18/2011 FINISH GOOD CHECKER C.D.O. FOOD SPHERE 18,000.00 N/A CONTRACTUAL N

06/21/2011 08/12/2013 SECURITY GUARD DELTA MIKE AGENCY 23,800.00 N/A 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 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
N/A N/A
N/A N/A N/A N/A

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

DRIVING 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? 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 any court? YES ✘ NO
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 YES ✘ NO
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, YES ✘ NO
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 YES ✘ NO
Barangay election)? If YES, give details:

b. Have you resigned from the government service during the three (3)-month period before the last YES ✘ NO
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? YES ✘ NO
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? YES ✘ NO
If YES, please specify:
b. Are you a person with disability? 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
ATTY. FRANCIS JAMES E. MEER CAUAYAN CITY, ISABELA 3.5 cm. X 4.5 cm
(passport size)

ATTY. MARICEL R. EVANGELISTA ALICIA, ISABELA With full and handwritten

name tag and signature over
printed name
ATTY. CEZAR ELVIN SECOLLES ECHAGUE, ISABELA
Computer generated
42. or photocopied picture
I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and is not 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 verify/validate the contents stated herein.
I agree that any misrepresentation made in this document and its attachments shall cause the filing of PHOTO
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: DRIVER'S LICENSE
ID/License/Passport No.: C05-12-011929
Signature (Sign inside the box)

Date/Place of Issuance: LTO, CAUAYAN CITY, ISABELA

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