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The document is a Personal Data Sheet (CS Form No. 212) that collects personal information of an individual named John Lloyd Rivera, including details about his birth, citizenship, and family background. It also outlines his educational background, highlighting his achievements and current enrollment in a Bachelor of Secondary Education program. The form includes warnings about misrepresentation and instructions for completion.

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Lester Juliano Suba
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53 views1 page

PDS Page 1

The document is a Personal Data Sheet (CS Form No. 212) that collects personal information of an individual named John Lloyd Rivera, including details about his birth, citizenship, and family background. It also outlines his educational background, highlighting his achievements and current enrollment in a Bachelor of Secondary Education program. The form includes warnings about misrepresentation and instructions for completion.

Uploaded by

Lester Juliano Suba
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CS Form No.

212

PERSONAL DATA SHEET


Revised 2017

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 RIVERA

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

MIDDLE NAME LUCERO


3. DATE OF BIRTH
(mm/dd/yyyy)
09/17/2003 16. CITIZENSHIP Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH SAN JOSE CITY, NUEVA ECIJA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female N/A
6 CIVIL STATUS Single Married 17. RESIDENTIAL ADDRESS 779 ZONE 4
Widowed Separated House/Block/Lot No. Street
Other/s:
N/A PALESTINA
Subdivision/Village Barangay
7. HEIGHT (m) 1.69 SAN JOSE CITY NUEVA ECIJA
City/Municipality Province
8. WEIGHT (kg) 68 ZIP CODE 3121

9. BLOOD TYPE A+ 18. PERMANENT ADDRESS 779 ZONE 4


House/Block/Lot No. Street
10. GSIS ID NO. N/A N/A PALESTINA
Subdivision/Village Barangay
11. PAG-IBIG ID NO. N/A SAN JOSE CITY NUEVA ECIJA
City/Municipality Province
12. PHILHEALTH NO. N/A ZIP CODE 3121

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

14. TIN NO. N/A 20. MOBILE NO. 09063847827

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) riverajohnlloyd5@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 RIVERA
NAME EXTENSION (JR., SR) N/A
FIRST NAME REYNALDO
MIDDLE NAME LUCERO
25. MOTHER'S MAIDEN NAME

SURNAME LUCERO
FIRST NAME LUALHATI
MIDDLE NAME GRUBANZO (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
SCHOLARSHIP/
26. PERIOD OF ATTENDANCE HIGHEST LEVEL/
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE YEAR ACADEMIC
LEVEL UNITS EARNED
(Write in full) (Write in full) (if not graduated)
GRADUATED HONORS
From To RECEIVED

ELEMENTARY PALESTINA ELEMENTARY SCHOOL PRIMARY EDUCATION 2010 2016 GRADUATED 2016 WITH HONORS

SAN JOSE CITY, NATIONAL HIGH WITH HIGH


SECONDARY HIGH SCHOOL 2016 2022 GRADUATED 2022
SCHOOL HONORS

VOCATIONAL /
N/A N/A N/A N/A N/A N/A N/A
TRADE COURSE

BACHELOR OF SECONDARY EDUCATION MAJOR IN UNIVERSITY


COLLEGE CENTRAL LUZON STATE UNIVERSITY ENGLISH 2022 PRESENT 3RD YEAR N/A SCHOLAR

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE 05/10/2025


CS FORM 212 (Revised 2017), Page 1 of 4

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