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 EBASAN
NAME EXTENSION (JR., SR)
FIRST NAME ROSABELLE

MIDDLE NAME BARRERA

3. DATE OF BIRTH
(mm/dd/yyyy) 11/15/1995 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by naturalization
ILALAN, YUPISAN, PAMPLONA,
4. PLACE OF BIRTH If holder of dual citizenship, Pls. indicate country:
NEG. OR.
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS N/A N/A

Widowed Separated House/Block/Lot No. Street
N/A ILALAN
Other/s:
Subdivision/Village Barangay
PAMPLONA NEGROS ORIENTAL
7. HEIGHT (m) 1.52
City/Municipality Province
8. WEIGHT (kg) 70 ZIP CODE 6205
18. PERMANENT ADDRESS N/A N/A
9. BLOOD TYPE AB+
House/Block/Lot No. Street
N/A ILALAN
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121274561270 PAMPLONA NEGROS ORIENTAL

City/Municipality Province
12. PHILHEALTH NO. 122026443898 ZIP CODE 6205

13. SSS NO. 3496980854 19. TELEPHONE NO. N/A

14. TIN NO. N/A 20. MOBILE NO. 09553353643

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) rosabellebarrera09@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME EBASAN 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME STANLEY SKYLER B. EBASAN 10/23/2021

MIDDLE NAME TINAMBACAN SPENCER B. EBASAN 2/16/2023

OCCUPATION UNEMPLOYED

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. 9364367470

24. FATHER'S SURNAME BARRERA

NAME EXTENSION (JR., SR)
FIRST NAME RICHARD

MIDDLE NAME CATACUTAN

25. MOTHER'S MAIDEN NAME BALLERMO

SURNAME BARRERA

FIRST NAME ANABELIA

MIDDLE NAME LAGUTOM (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
UNITS ACADEMIC
LEVEL (Write in full) EARNED
GRADUATED
HONORS
(Write in full) (if not RECEIVED
From To
graduated)
PAMPLONA CENTRAL ELEMENTARY
ELEMENTARY
SCHOOL
ELEMENTARY GRADUATE 2002 2008 2008 N/A
VOCATIONAL /
SECONDARY PAMPLONA NATIONAL HIGH SCHOOL HIGH SCHOOL GRADUATE 2008 2013 2013 N/A
DEAN'S LIST,
N/A N/A N/A N/A N/A N/A
PRESIDENTIAL
TECHNOLOGY &
PRESIDENTIAL
NEGROS ORIENTAL STATE BACHELOR OF SCIENCE IN AGRICULTURE
COLLEGE TRADE 2016 2020 2020 ACADEMIC AWARD

COURSE UNIVERSITY- PAMPLONA CAMPUS MAJOR IN AGRONOMY (LANDBANK GAWAD

PATNUBAY
SCHOLARSHIP
GRADUATE STUDIES PROGRAM in
partnership of IRRI)

(Continue on separate sheet if necessary)

SIGNATURE DATE
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 1080 AGRICULTURIST BOARD PASSER 78.8 NOVEMBER 21-23, 2022 CEBU CITY N/A 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
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To
(Y/ N)
10/1/2020 12/24/2021 BACK UP SUPPORT/OFFICE STAFF BUFFALO FARM SUPPLY 9,000-10,000 MINIMUM RESIGN N

8/10/2022 2/3/2023 TELLER OCEAN FAST FERRIES INC. 9,000-10,000 MINIMUM RESIGN N

(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
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (Write in
full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

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

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

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

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

(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 ✘ NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘ NO
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
YES ✘ NO
regulation 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 If YES, give details:
phased out (abolition) in the public or private sector? ________________________________
I resigned, due to some important reason.
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year YES ✘ NO
(except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
the last 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
a.
items:
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
GENARO LASTIMADO CEBU CITY 9190665967 3.5 cm. X 4.5 cm
(passport size)

PETER PAGENTE SIQUIJOR 9190665964 With full and handwritten

name tag and signature over
printed name
DARLYN POSAS PAMPLONA 9157595625
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied picture
is not acceptable
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 PHOTO
filing of 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: NATIONAL ID

ID/License/Passport No.: 5196-2173-0632-9467

Signature (Sign inside the box)

Date/Place of Issuance: MARCH 28, 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