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 Langbayan
NAME EXTENSION (JR., SR)
FIRST NAME Sunshine
MIDDLE NAME Tino
3. DATE OF BIRTH
(mm/dd/yyyy) 1/27/1992 16. CITIZENSHIP
4. PLACE OF BIRTH Malabing Kasibu Nueva Vizcaya If holder of dual citizenship, Filipino Pls. indicate country:
please indicate the details.
5. SEX female
17. RESIDENTIAL ADDRESS
6 CIVIL STATUS
House/Block/Lot No. Street
married
Subdivision/Village Barangay
Kasibu
7. HEIGHT (m)
City/Municipality Province
8. WEIGHT (kg) 50 ZIP CODE 3703
18. PERMANENT ADDRESS
9. BLOOD TYPE 0
House/Block/Lot No. Street
10. GSIS ID NO.
Subdivision/Village Barangay
11. PAG-IBIG ID NO.
Kasibu
City/Municipality Province
12. PHILHEALTH NO. ZIP CODE 3703
13. SSS NO. 19. TELEPHONE NO.
14. TIN NO. 625676558000 20. MOBILE NO. 09559859058
15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any)
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME Abbac 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME Napoleon
MIDDLE NAME Laglag
OCCUPATION farmer
EMPLOYER/BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.
24. FATHER'S SURNAME Langbayan
NAME EXTENSION (JR., SR)
FIRST NAME Honorio
MIDDLE NAME Gumawi
25. MOTHER'S MAIDEN NAME
SURNAME Tino
FIRST NAME Analiza
MIDDLE NAME Waren (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 Malabing Kasibu east central school
SECONDARY /
VOCATIONAL Don Bosco High school
TRADE
COURSE
COLLEGE Ifugao State University Midwifery 2011
GRADUATE STUDIES
(Continue on separate sheet if necessary)
SIGNATURE DATE sept. 20,2023
CS FORM 212 (Revised 2017), Page 1 of 4
May
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)
May June Vaccinator DOH 27000.00
(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
(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
(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)
(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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
No
35. a. Have you ever been found guilty of any administrative offense?
No
b. Have you been criminally charged before any court?
No
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?
No
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 No
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)?
No
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 candidate? No
39. Have you acquired the status of an immigrant or permanent resident of another country?
No
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? No
If YESN
b. Are you a person with disability?
If YES, please specify ID No: No
c. Are you a solo parent?
If YES, please specify ID No: 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
4.5 cm. X 3.5 cm
(passport size)
Computer generated
or photocopied picture
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:
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
