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 Baysa
NAME EXTENSION (JR., SR)
FIRST NAME Judy
MIDDLE NAME Almerol
3. DATE OF BIRTH
10/18/1989 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH Poblacion 2 Tubay Agusan Del Norte If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female
6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS District 3
Widowed House/Block/Lot No. Street
Separate
Punta
Other/s: d
Subdivision/Village Barangay
8602 Nasipit Agusan Del Norte
7. HEIGHT (m) 5'10''
City/Municipality Province
8. WEIGHT (kg) 70kg ZIP CODE
18. PERMANENT ADDRESS District 3
9. BLOOD TYPE B
House/Block/Lot No. Street
Punta
10. GSIS ID NO. N/A
Subdivision/Village Barangay
11. PAG-IBIG ID NO. 1211-3181-8722
8602 Nasipit Agusan Del Norte
City/Municipality Province
12. PHILHEALTH NO. 18-050057693-4 ZIP CODE 8602
13. SSS NO. 08-1635959-2 19. TELEPHONE NO. 085-8083025
14. TIN NO. 443-869-492-000 20. MOBILE NO 9165278724 09165278724
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) judybaysa101889@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME Nahial 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) Xerxes Jude N. Baysa
FIRST NAME Mary Ann 9/21/2015
MIDDLE NAME Batiancila Maria Hadassah N. Baysa 12/20/2018
OCCUPATION Government Employee Maria Alliyah N. Baysa 4/13/2020
EMPLOYER/BUSINESS NAME DSWD
BUSINESS ADDRESS Butuan City
TELEPHONE NO.
24. FATHER'S SURNAME Baysa
FIRST NAME Pablo
MIDDLE NAME Ampit
25. MOTHER'S MAIDEN NAME
SURNAME Almerol
FIRST NAME Yolanda
MIDDLE NAME Cepeda (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 Tubay Central Elementary School 6/1/1993 4/2/2003 2003
SECONDARY /
VOCATIONAL Tubay National High School 6/3/2003 4/7/2007 2007
Monark Foundation Institute 7/4/2011 7/7/2013 2013
TRADE
COURSE
COLLEGE
GRADUATE STUDIES
(Continue on separate sheet if necessary)
SIGNATURE DATE 0//29/2024
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
221602020039
NATIONAL CERTIFICATE 2 TESDA CALAMBA LAGUNA 11/15/2027
02
(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)
2/17/2022 10/31/2022 HEAVY EQUIPMENT MECHANIC SAN ROQUE METALS INC. 18000.00 CASUAL
11/5/2018 1/6/2021 PRODUCT SUPPORT TECHNICIAN SITECH-PHL.1NC. 17000.00 REGULAR
8/29/2017 10/20/2018 MECHANIC EQUI-PARCO CONSTRUCTION COMPANY 12000.00 CASUAL
1/30/2017 7/14/2017 PRODUCT SUPPORT TECHNICIAN SITECH-PHL.1NC. 16000.00 CASUAL
8/1/2013 8/1/2015 HEAVY EQUIPMENT MECHANIC SAN ROQUE METALS INC. 12500.00 REGULAR
(Continue on separate sheet if necessary)
SIGNATURE DATE 01/29/2024
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
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
LEADERSHIP TRAINING PROGRAM 12/6/2011 12/10/2011 50.0 TECHNICAL MONARK FOUNDATION INSTITUTE
BASIC TRAINING ON USA 88 LUBRICANT PRODUCT APPLICATION 9/8/2018 9/8/2018 8.0 TECHNICAL CHEMICAL ALLOY CORPORATION
BEARING BASIC SEMINAR 6/22/2018 6/22/2018 8.0 TECHNICAL NSK ASEAN AND OCEANA Pte., ltd
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)
n/a n/a n/a
(Continue on separate sheet if necessary)
SIGNATURE DATE 01/29/2024
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? RESIGN
________________________________
________________________________
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
DENMARK MARCELINO E.RODRIGUEZ JR QUEZON CITY 9175006337 4.5 cm. X 3.5 cm
(passport size)
JOHN NOFUENTE TUBAY AGUSAN DEL NORTE 9064655254
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: DRIVERS LICENSE
ID/License/Passport No.: K01-14-003102
Signature (Sign inside the box)
Date/Place of Issuance: 10/18/2022
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
