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 MENDOZA
NAME EXTENSION (JR., SR)
FIRST NAME JHERRY MAE

MIDDLE NAME HICAP

3. DATE OF BIRTH
(mm/dd/yyyy) 16. CITIZENSHIP
10/31/1997

4. PLACE OF BIRTH MALABON MANILA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX FEMALE FILIPINO

6 CIVIL STATUS MARRIED

17. RESIDENTIAL ADDRESS SANTO NIÑO
House/Block/Lot No. Street
MT. VIEW
Subdivision/Village Barangay

7. HEIGHT (m) 5'4 MARIVELES BATAAN

City/Municipality Province
8. WEIGHT (kg) 53 ZIP CODE 2105

9. BLOOD TYPE O
18. PERMANENT ADDRESS 118 SAMARIA HEIGHTS
House/Block/Lot No. Street

10. GSIS ID NO. N/A MT. VIEW

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1211 8628 6651 MARIVELES BATAAN

City/Municipality Province

12. PHILHEALTH NO. 07-051067447-0 ZIP CODE 2105

13. SSS NO. 02-4108908-4 19. TELEPHONE NO. N/A

14. TIN NO. 333631439 20. MOBILE NO. 09667239029

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) jhemaehicap@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME MENDOZA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME JEFFERSON

MIDDLE NAME OGSIMER

OCCUPATION COORDINATOR

EMPLOYER/BUSINESS NAME ENVIROKONSULT

BUSINESS ADDRESS
KONSULT HAUS 9030 FERIA ROAD POOK DELA PAZ, OLD
BALATARA QUEZON CITY
TELEPHONE NO. N/A

24. FATHER'S SURNAME HICAP

NAME EXTENSION (JR., SR)
FIRST NAME JUAN

MIDDLE NAME HERRERA

25. MOTHER'S MAIDEN NAME

SURNAME COCHESA

FIRST NAME ELSA

MIDDLE NAME ROQUE (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

2003 2010
ELEMENTARY MT. VIEW ELEMENTARY SCHOOL PRIMARY 2010

2010 2014
SECONDARY CABCABEN NATIONAL HIGH SCHOOL SECONDARY 2014
VOCATIONAL /

TRADE
COURSE
COLLEGE

GRADUATE STUDIES

(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 N/A N/A N/A 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
(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)

11/15/2016 10/15/2021 TABLEWORKS/MACHINE OPERATOR FCF MANUFACTURING CORP. 10000.00 N/A REGULAR N

1/5/2023 5/5/2023 SEWER N/A

(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 N/A N/A N/A 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

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

(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)

SEWER N/A 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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
________________________________
________________________________
35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
________________________________

b. Have you been criminally charged before any court?

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?
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 If YES, give details:
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)?
If YES, give details:
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?
If YES, give details:

39. Have you acquired the status of an immigrant or permanent resident of another country?
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?
If YES, please specify:
b. Are you a person with disability?
If YES, please specify ID No:
c. Are you a solo parent?
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
4.5 cm. X 3.5 cm
JULIE ANN PONPON BAKERY ALAS-ASIN 9097041243 (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 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: UMID

ID/License/Passport No.: 02-4108908-4

Signature (Sign inside the box)

Date/Place of Issuance: SSS BALANGA

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