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 again
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. (D

I. PERSONAL INFORMATION
2. SURNAME TILLAMA
NAME EXTENSION (JR., S
FIRST NAME JAY-AR N/A
MIDDLE NAME BENWIHAN
3. DATE OF BIRTH
(mm/dd/yyyy) May 05,1993 16. CITIZENSHIP ✘ Filipino Dual Citizenship
✘ by birth

4. PLACE OF BIRTH Napo, Ambaguio, Nueva Vizcaya If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS N/A
Widowed Separated House/Block/Lot No.

Other/s:
UUBI POB
Subdivision/Village B
7. HEIGHT (m) 1.605 m. AMBAGUIO NUEV
City/Municipality P
8. WEIGHT (kg) 74 Kls. ZIP CODE 3701
18. PERMANENT ADDRESS N/A
9. BLOOD TYPE "B"
House/Block/Lot No.
UUBI POB
10. GSIS ID NO. N/A
Subdivision/Village B
AMBAGUIO NUEVA
11. PAG-IBIG ID NO. N/A
City/Municipality P

12. PHILHEALTH NO. N/A ZIP CODE 3701

13. SSS NO. N/A 19. TELEPHONE NO. N/A
14. TIN NO. 451-391-589-000 20. MOBILE NO. 0936-556-5799
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) Jay_Tillama@yahoo.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)

NAME EXTENSION (JR., SR)

FIRST NAME N/A N/A JHYLES JARED R. TILLAMA
MIDDLE NAME N/A N/A
OCCUPATION N/A N/A
EMPLOYER/BUSINESS NAME N/A N/A
BUSINESS ADDRESS N/A N/A
TELEPHONE NO. N/A N/A
24. FATHER'S SURNAME TILLAMA N/A
NAME EXTENSION (JR., SR)
FIRST NAME JOSEPH N/A N/A
MIDDLE NAME PILOSAN N/A
25. MOTHER'S MAIDEN NAME BENWIHAN N/A
SURNAME TILLAMA N/A
FIRST NAME MARTHA N/A
MIDDLE NAME BALACTAS (Continue on separate sheet if necessa

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL HIGHEST LEVEL/
26. BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE UNITS
LEVEL (Write in EARNED
(Write in full)
full) (if not graduated)
From To
June March
ELEMENTARY NAPO ELEMENTARY SCHOOL ELEMENTARY N/A
2000 2006
VOCATIONAL June March
SECONDARY / NAPO TU-YAK INTEGRATED SCHOOL SECONDARY N/A
2006 2010
N/A N/A N/A N/A N/A
TRADE
 NUEVA VIZCAYA STATE UNIVERSITY BACHELOR OF SCIENCE IN June April
COLLEGE N/A
-BAYOMBONG CAMPUS GEODETIC ENGINEERING 2010 2016
GRADUATE STUDIES N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE June

CS FOR
 DATA SHEET
nce Sheet shall cause the filing of administrative/criminal case/s against the person

ORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

N/A

Dual Citizenship

by naturalization

Pls. indicate country:

N/A
Street
POBLACION
Barangay
NUEVA VIZCAYA
Province

3701
N/A
Street
POBLACION
Barangay
NUEVA VIZCAYA
Province

3701
N/A

0936-556-5799

Jay_Tillama@yahoo.com

DATE OF BIRTH (mm/dd/yyyy)

11/21/2014
N/A
N/A
N/A
N/A
N/A

04/15/1963

12/24/1969

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2006 N/A

2010 N/A

N/A N/A
 2016 N/A

N/A N/A
rate sheet if necessary)

June 9, 2019
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
RA No. 8560 As Amended by RA No. 9200 and May 05,
70% 10/25-26/2017 SAMPALOC, MANILA, PHILIPPINES 0010060
RA No. 8981 2020

(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)
Department Of Public Works and
1/8/2018 12/31/2019 Engineer I Highways Ifugao First District Engineering 221,348.00 N/A Job Order Y
Office, Lagawe, Ifugao

Department Of Agrarian Reform

03/19/2018 06/19/2018 Job of Contract-Geodetic Engineer 15,000.00 N/A Job Contract Y
Provincial Office of Nueva Vizcaya

Municipal Assessor Office-Local

10/1/2017 06/30/2018 Tax Mapping Aide 1 Government Unit, Ambaguio, Nueva 7,000.00 N/A Job Order Y
Vizcaya

(Continue on separate sheet if necessary)

SIGNATURE DATE JUNE 9, 2019

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 /
From To

Lutheran Church in the Philippines Youth Organization, Nueva Vizcaya Chapter 2/3/2014 Present N/A M

Association of Geodetic Engineering Students (AGES) 7/6/2010 12/4/2016 N/A M

Kalanguya Student Organization (KSO) 06/14/2010 12/4/2016 N/A M

(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/ S
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/
Technical/etc)
From To

45th Annual Regional Convention & Seminar (Stronger and United GEP to Sustain Geodetic Eng
12/5/2019 05/13/2019 16 Hrs Technical
Global Competence) Inc. Region 0
Department o
Civil 3D and Arc GIS Technical Workshop Training 07/26/2018 07/27/2018 16 Hrs Technical First District E
Design Sectio
44th Annual Regional Convention & Seminar (Bringing Technology to the Grassroots Geodetic Eng
04/13/2018 04/14/2018 16 Hrs Technical
for World Class Professionals) Inc. Region 0

2017 General Revision Of Real Property Assessments Technical Training-Workshop 11/28/2016 1/12/2016 24 Hrs Technical Provincial Ass
Seminars on AutoCad and Land Desktop: Shifting to High Gear towards Integrity and Department o
10/2/2014 10/2/2014 4 Hrs Technical
Excellence in the Geodetic Engineering Proffesion Vizcaya State

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERS
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

Computer Literate (Microsoft Word, Microsoft Member, Geo

N/A
Excel) Organization,
AutoCAD/Civil 3D Literate N/A

Driving Motorcycle
 (Continue on separate sheet if necessary)

SIGNATURE DATE
EOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

Member

Member

Member

rate sheet if necessary)

GRAMS ATTENDED
(5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

Geodetic Engineers of the Philippines,

Inc. Region 02
Department of Public Works and Highways Ifugao
First District Engineering Office, Planning and
Design Section, Lagawe Ifugao
Geodetic Engineers of the Philippines,
Inc. Region 02

Provincial Assessor Office Of Nueva Vizcaya

Department of Geodetic Engineering-Nueva
Vizcaya State University-Bayombong Campus

rate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in
full)

Member, Geodetic Engineers of the Philippines'

Organization, Nueva Vizcaya Chapter
rate sheet if necessary)

JUNE 9, 2019
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:
N/A
35. a. Have you ever been found guilty of any administrative offense? YES ✘ NO
If YES, give details:
________________________________N/A
________________________________
b. Have you been criminally charged before any court? YES ✘ NO
If YES, give details:
Date Filed: N/A
________________________________
Status of Case/s: N/A
________________________________

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:
________________________________N/A
________________________________
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? ________________________________
Finished Con
________________________________
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: N/A
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: N/A
39. Have you acquired the status of an immigrant or permanent resident of another country? YES NO
If YES, give details (country):
N/A
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 w
the last 6 mon
Poblacion, Ambaguio, Nueva
MR. ROGELIO L. MINAS Vizcaya
0997-314-5775 3.5 cm. X 4.5 c
(passport size
0926-831- With full and handw
MR. ROLLY T. HAWETTE Papaya, Kasibu, Nueva Vizcaya
2082 name tag and signat
printed name
Tiblac, Ambaguio, Nueva Vizcaya 0997-329-
MR. DECORAN G. ALLAWAS
4774 Computer genera
or photocopied pi
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and is not acceptab
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: PRC
ID/License/Passport No.: 0010060 Signature (Sign inside the box)
11/26/2017 JUNE 9, 2019
Date/Place of Issuance:
-Sampaloc, Manila Date Accomplished Right Thumbma

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated a

Person Administering Oath

CS FORM 212 (Revise

 If YES, give details:
N/A

If YES, give details:

________________________________N/A
________________________________

If YES, give details:

N/A
________________________________
N/A
________________________________

If YES, give details:

________________________________N/A
________________________________

If YES, give details:

________________________________
Finished Contract
________________________________
✘ NO
N/A
✘ NO
N/A

NO
If YES, give details (country):
N/A

NO
KALANGUYA
✘ NO
N/A
✘ NO
N/A

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

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

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