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 LORA
NAME EXTENSION (JR., SR)
FIRST NAME JOEL

MIDDLE NAME PEDROSA

3. DATE OF BIRTH
(mm/dd/yyyy) 4/16/1982 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH PALO, 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 BLOCK 6 LOT 18

Widowed House/Block/Lot No. Street

Separate
d VER DOMINIC HEIGHTS SUBDIVISION SAN JOSE
Other/s:
Subdivision/Village Barangay
PALO LEYTE
7. HEIGHT (m) 1.6
City/Municipality Province
8. WEIGHT (kg) 60 ZIP CODE 6501

9. BLOOD TYPE N/A 18. PERMANENT ADDRESS BLOCK 6 LOT 18

House/Block/Lot No. Street
VER DOMINIC HEIGHTS SUBDIVISION SAN JOSE
10. GSIS ID NO. N/A
Subdivision/Village Barangay
PALO LEYTE
11. PAG-IBIG ID NO. N/A
City/Municipality Province

12. PHILHEALTH NO. 132013790322 ZIP CODE

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

14. TIN NO. 438-423-000 20. MOBILE NO. 09851652299

15. AGENCY EMPLOYEE NO. PGO-JO330 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/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME N/A 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 LORA

NAME EXTENSION (JR., SR)
FIRST NAME RODOLFO

MIDDLE NAME MENDAZA

25. MOTHER'S MAIDEN NAME

SURNAME PEDROSA

FIRST NAME LOLITA

MIDDLE NAME SPAÑA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY NAGA-NAGA ELEMENTARY SCHOOL PRIMARY 1997 2003 N/A 2003 N/A

SECONDARY SAN JOAQUIN NATIONAL HIGH SCHOOL SECONDARY 2003 2007 N/A 2007 N/A
VOCATIONAL /

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

TRADE
COURSE
COLLEGE
EASTERN VISAYAS STATE UNIVERSITY BACHELOR OF ARTS IN ECONOMICS 2007 2008 16 N/A N/A
TACLOBAN CITY

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

(Continue on separate sheet if necessary)

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

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

APRIL 2023 PRESENT UTILITY WORKER LEYTE CONVENTION CENTER/LTIPC-PGO 8,250.00 N/A JO Y

JUNE 5, 2010 FEB. 28, 2023 UTILITY WORKER LOCAL GOVERNMENT UNIT-PALO, LEYTE 7,000.00 N/A JO Y

(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

(Continue on separate sheet if necessary)

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

CAPABILITY BUILDING TRAINING WRITESHOP ON MINUTES TAKING AND DRAFTING BOARD PRESIDENTIAL COMMISSION FOR THE URBAN POOR
RESOLUTIONS AND BASIC ACCOUNTING FOR NON-ACCOUNTANTS CUM ORIENTATION ON 7/31/2023 7/31/2023 8 MANAGERIAL FIELD OPERATIONS DIVISION FOR THE VISAYAS
FINANCIAL LITERACY

CAPABILITY BUILDING TRAINING ON DISASTER RISK REDUCTION AND MANAGEMENT, FIRE 4/21/2023 7/31/2023 8 TECHNICAL PRESIDENTIAL COMMISSION FOR THE URBAN POOR
SAFETY AND PREVENTION AND FIRST AID RESPONSE IN EMERGENCY SITUATION FIELD OPERATIONS DIVISION FOR THE VISAYAS

ORGANIZATIONAL MANAGEMENT SEMINAR 12/7/2022 7/31/2023 8 MANAGERIAL LOCAL GOVERNMENT UNIT-PALO, LEYTE

BUNKHOUSES AND TRANSITIONAL SHELTERS ANNUAL BEST IN WASH MANAGEMENT AND BEST 11/11/2015 7/31/2023 8 TECHNICAL UNITED NATIONS INTERNATION CHILDREN'S
IN GARDENING PROJECT CELEBRATION DAY EMERGENCY FUND

TRAINING ON COMMUNITY-BASED MONITORING SYSTEM MODULE APPLICATIONS DATA 1/27/2015 7/31/2023 24 TECHNICAL MUNICIPAL PLANNING AND DEVELOPMENT
COLLECTION USING CBMS SCAN AND CBMS PORTAL COORDINATOR

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

SINGING N/A REFORMIST GUARDIANS INTERNATIONAL

COOKING

GARDENING

(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 ✘

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
by any court or tribunal? YES ✘ NO
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 ✘ YES NO
out (abolition) in the public or private sector? If YES, give details:
________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? YES ✘ NO
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
FRANCES ANN B. PETILLA PALO, LEYTE - 4.5 cm. X 3.5 cm
(passport size)

CLAIRE MADERAZO TACLOBAN CITY 09151806028

Computer generated
or photocopied picture
FLORIDA ISRAEL TACLOBAN CITY 09268613307 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
administrative/criminal case/s against me. 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: NATIONAL IDENTIFICATION

ID/License/Passport No.: 4132-6980-5740-7903 Signature (Sign inside the box)

Date/Place of Issuance: MAY 19, 2022/PALO, LEYTE 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