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 DE LOS SANTOS
NAME EXTENSION (JR., SR)
FIRST NAME TRISTAN ROY

MIDDLE NAME AQUINO

3. DATE OF BIRTH
6/20/1998 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH CALBAYOG CITY EASTERN VISAYAS If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS 27A LORIGA GALLARZA ST.

Widowed House/Block/Lot No. Street

Separate
SAN ANTONIO
Other/s: d
Subdivision/Village Barangay
APARRI CAGAYAN
7. HEIGHT (m) 1.68
City/Municipality Province
8. WEIGHT (kg) 60 ZIP CODE 3515

18. PERMANENT ADDRESS 27A LORIGA GALLARZA ST.

9. BLOOD TYPE
House/Block/Lot No. Street
SAN ANTONIO
10. GSIS ID NO.
Subdivision/Village Barangay
APARRI CAGAYAN
11. PAG-IBIG ID NO. 1212-5824-5314
City/Municipality Province

12. PHILHEALTH NO. 06-025377402-1 ZIP CODE 3515

13. SSS NO. 01-2921948-4 19. TELEPHONE NO.

14. TIN NO. 379-810-888-000 20. MOBILE NO. 09311550283

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

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME DE LOS SANTOS

NAME EXTENSION (JR., SR)
FIRST NAME NONILONE

MIDDLE NAME VILLA

25. MOTHER'S MAIDEN NAME

SURNAME DE LOS SANTOS

FIRST NAME ROWENA

MIDDLE NAME AQUINO (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
(Write in full) HONORS
full) (if not graduated) RECEIVED
From To

ELEMENTARY TUGUEGARAO NORTH EAST CENTRAL SCHOOL 2005/2011

SECONDARY /
VOCATIONAL APARRI SCHOOL OF ARTS AND TRADES 2011/2015

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

TRADE
Service
COURSE
COLLEGE CAGAYAN STATE UNIVERSITY APARRI Bachelor of Science in Information Technology 2015/2019
Award

GRADUATE STUDIES N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE July 21,2023

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

(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
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)
Contract of
11/18/2019 12/31/2019 SALES CLERK SAVEMORE APARRI 9620.00 N/A N
Service
Contract of
9/19/2021 7/19/2023 SALES PROMODISER SAVEMORE APARRI 11700.00 N/A N
Service

(Continue on separate sheet if necessary)

SIGNATURE DATE July 21,2023

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

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
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) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To

IT Productive Tools Seminar and Workshop 1/21/2019 1/25/2019 8 hours CICS Academic Building

(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 in
(Write in full)
full)
Alumni Tracking System for Cagayan State
Best Undergraduate Paper Award
University
Alumni Tracking System for Cagayan State
Best Capstone Project (web track)
University
Most Outstanding Athlete of the Year

(Continue on separate sheet if necessary)

SIGNATURE DATE July 21,2023

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
b. within the fourth degree (for Local Government Unit - Career Employees)? YES
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
(078)844- the last 6 months
Corazon T. Talamayan, Ph D Macanaya Aparri, Cagayan
0098/0099 4.5 cm. X 3.5 cm
(passport size)

Fredesvinda A. Ablog Maura Aparri, Cagyan 9174876390

Computer generated
or photocopied picture
Leo Paliwanan Maura Aparri, Cagyan 9752423217 is not acceptable

42. 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 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: N/A

ID/License/Passport No.: B03-22000126

Signature (Sign inside the box)
July 21,2023
Date/Place of Issuance: 01/25/2022 Aparri Cagayan
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