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 LLEVADO
NAME EXTENSION (JR., SR)
FIRST NAME ANTONIETA

MIDDLE NAME LAMATA

3. DATE OF BIRTH
(mm/dd/yyyy) 6/13/1962 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH TACLOBAN CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS CLASSTER 2 74

Widowed House/Block/Lot No. Street

Separate
d BLISS I NULA-TULA
Other/s:
Subdivision/Village Barangay
TACLOBAN LEYTE
7. HEIGHT (m) 5'1
City/Municipality Province
8. WEIGHT (kg) 45kg ZIP CODE 6500

18. PERMANENT ADDRESS CLASSTER 2 74

9. BLOOD TYPE O
House/Block/Lot No. Street
BLISS I NULA-TULA
10. GSIS ID NO.
Subdivision/Village Barangay
TACLOBAN LEYTE
11. PAG-IBIG ID NO. 121211663165
City/Municipality Province

12. PHILHEALTH NO. ZIP CODE 6500

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

14. TIN NO. 20. MOBILE NO. 09066062347

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) N/A

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME
NAME EXTENSION (JR., SR) N/A

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME LLEVADO (DECEASED)

NAME EXTENSION (JR., SR)
FIRST NAME NICASIO

MIDDLE NAME MARTIN

25. MOTHER'S MAIDEN NAME

SURNAME LAMATA (DECEASED)

FIRST NAME ROSITA

MIDDLE NAME BASAS (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST LEVEL/ SCHOLARSHIP/
26. NAME OF SCHOOL PERIOD OF ATTENDANCE
LEVEL (Write in BASIC EDUCATION/DEGREE/COURSE
(Write in full)
UNITS YEAR ACADEMIC
HONORS
full) EARNED GRADUATED
(if not graduated) RECEIVED
From To

ELEMENTARY LEYTE NORMAL UNINVERSITY LAB. SCHOOL 1970 1976 1976

SECONDARY LEYTE STATE COLLEGE 1976 1980 1980

VOCATIONAL /

TRADE
COURSE
COLLEGE DIVINE WORLD UNIVERSITY 1981 1982 COLLEGE
LEVEL

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE July 1, 2024

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)

7/1/2024 TO DATE ADMIN. AIDE I AGRICULTURE OFFICE 12980.00 CASUAL

1/1/2024 6/30/2024 ADMIN. AIDE I AGRICULTURE OFFICE 8250.00 J.O YES

1/1/2023 12/31/2023 ADMIN. AIDE I AGRICULTURE OFFICE 8250.00 J.O YES

1/1/2022 12/31/2022 ADMIN. AIDE I AGRICULTURE OFFICE 6500.00 J.O YES

1/1/2021 12/31/2021 ADMIN. AIDE I AGRICULTURE OFFICE 6500.00 J.O YES

1/1/2020 12/31/2020 ADMIN. AIDE I AGRICULTURE OFFICE 6500.00 J.O YES

1/1/2019 12/31/2019 ADMIN. AIDE I AGRICULTURE OFFICE 6500.00 J.O YES

1/1/2018 1/31/2018 ADMIN. AIDE I AGRICULTURE OFFICE 6500.00 J.O YES

1/1/2017 1/31/2017 ADMIN. AIDE I AGRICULTURE OFFICE 4400.00 J.O YES

1/1/2016 1/31/2016 ADMIN. AIDE I AGRICULTURE OFFICE 4400.00 J.O YES

1/1/2015 1/31/2015 ADMIN. AIDE I AGRICULTURE OFFICE 4400.00 J.O YES

1/1/2014 1/1/2014 ADMIN. AIDE I AGRICULTURE OFFICE 4400.00 J.O YES

1/1/2013 1/1/2013 ADMIN. AIDE I AGRICULTURE OFFICE 4400.00 J.O YES

1/1/2012 1/31/2012 ADMIN. AIDE I AGRICULTURE OFFICE 4400.00 J.O YES

1/1/2011 1/31/2011 ADMIN. AIDE I AGRICULTURE OFFICE 4400.00 J.O YES

1/1/2010 1/31/2010 ADMIN. AIDE I AGRICULTURE OFFICE 4400.00 J.O YES

1/1/2009 1/31/2009 ADMIN. AIDE I AGRICULTURE OFFICE 4400.00 J.O YES

1/1/2008 1/31/2008 ADMIN. AIDE I AGRICULTURE OFFICE 4400.00 J.O YES

1/1/2007 1/1/2007 ADMIN. AIDE I AGRICULTURE OFFICE 4400.00 J.O YES

(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)

N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE JULY 1, 2024

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 ✘

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
by any court or tribunal? YES ✘ NO
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 YES ✘ NO
out (abolition) in the public or private sector? If YES, give details:
________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? YES ✘ NO
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
RHODORA BONIFACIO PALO, LEYTE 4.5 cm. X 3.5 cm
(passport size)

FLORIDA ISRAEL PALO, LEYTE

Computer generated
or photocopied picture
CORAZON ALVERO PALO, LEYTE 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:

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