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 MASUBAY
NAME EXTENSION (JR., SR) N/A
FIRST NAME ROD
MIDDLE NAME BALANO
3. DATE OF BIRTH
(mm/dd/yyyy) 16. CITIZENSHIP
12\12 \2002 ✘
✘
4. PLACE OF BIRTH BRGY. CATIGBIAN TANAUAN, LEYTE If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘
6 CIVIL STATUS ✘ 17. RESIDENTIAL ADDRESS N/A N/A
House/Block/Lot No. Street
N/A GUINGAUAN
Subdivision/Village Barangay
7. HEIGHT (m) 154 CM TABON-TABON LEYTE
City/Municipality Province
8. WEIGHT (kg) 46.1 KG ZIP CODE 6508
9. BLOOD TYPE TYPE O+
18. PERMANENT ADDRESS N/A N/A
House/Block/Lot No. Street
10. GSIS ID NO. N/A N/A GUINGAUAN
Subdivision/Village Barangay
11. PAG-IBIG ID NO. N/A TABON-TABON LEYTE
City/Municipality Province
12. PHILHEALTH NO. N/A ZIP CODE 6504
13. SSS NO. N/A 19. TELEPHONE NO. N/A
14. TIN NO. N/A 20. MOBILE NO. 09079286973
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) Rodbalanomasubay@gmail.com
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 N/A
NAME EXTENSION (JR., SR) N/A N/A N/A
MIDDLE NAME N/A
OCCUPATION N/A
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME MASUBAY
FIRST NAME RENE
MIDDLE NAME CAPLIS
25. MOTHER'S MAIDEN NAME BALANO
SURNAME
FIRST NAME CORAZON
MIDDLE NAME DANQUE (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
HIGHEST LEVEL/
26. NAME OF SCHOOL PERIOD OF ATTENDANCE SCHOLARSHIP/
LEVEL (Write in BASIC EDUCATION/DEGREE/COURSE
(Write in full)
UNITS YEAR ACADEMIC HONORS
full) EARNED GRADUATED RECEIVED
(if not graduated)
From To
ELEMENTARY GUINGAUAN ELEMENTARY SCHOOL ELEMENTARY 2009 2015 GRADUATED 2015 ACADEMIC
AWARDEE
SECONDARY TANAUAN NATIONAL HIGHSCHOL HIGH SCHOOL 2015 2021 GRADUATED 2021 ACADEMIC
AWARDEE
TANAUAN NATIONAL HIGHSCHOL SENIOR HIGH SCHOOL 12/7/2019 7/13/1905 GRADUATED 2021 ACADEMIC
AWARDEE
COLLEGE
EASTERN VISAYAS STATE UNIVERSITY BSA PRESENT PRESENT
BURAUEN CAMPUS
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
***NOTHING FOLLOWS***
(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 SERVICE
28. INCLUSIVE DATES SALARY/ JOB/
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY PAY GRADE (if STATUS OF
(Write in full/Do not (Write in MONTHLY SALARY applicable)& STEP
APPOINTMENT
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To (Y/ N)
N/A N/A N/A N/A N/A N/A N/A N/A
***NOTHING FOLLOWS***
(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
(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 ATTENDANCE
30. Type of LD
TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS (Write ( Managerial/
CONDUCTED/ SPONSORED BY (Write in full)
in full) (mm/dd/yyyy) NUMBER OF HOURS
Supervisory/
Technical/etc)
From To
TEACHER'S INTERNS AND ON-THE-JOB TRAINING STUDENT'S ORIENTATION SEMINAR O NN WORK
ETHICS. 01/10/2025 10/01/2025 8 HOURS TECHNICAL EASTERN VISAYAS STATE UNIVERSITY
***NOTHING FOLLOWS***
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
31. SPECIAL SKILLS and HOBBIES 32. NON-ACADEMIC DISTINCTIONS / RECOGNITION (Write in full) 33. MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in full)
TIME MANAGEMENT N/A N/A
BASKETBALL ***NOTHING FOLLOWS***
ONLINE GAMES
***NOTHING FOLLOWS***
(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? ________________________________
Resignation, due to personal issues
________________________________
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 CEL. NO.
ID picture taken within
the last 6 months
MARIA CRISANDRA D. OLIVEROS CARIDAD BAYBAY, LEYTE 9272978826 3.5 cm. X 4.5 cm
(passport size)
JAYMARK A. CAZEREZ PALALE 2 MCARTHUR, LEYTE 9508969781 With full and handwritten
name tag and signature over
printed name
MILDRED DEGUERIO BURAUEN, LEYTE 9305240458
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
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable
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: NATIONAL IDENTIFICATION
ID/License/Passport No.: 3248-1479-8620-9534 Signature (Sign inside the box)
Date/Place of Issuance: 08\30\2019 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
