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 SISON
N/A
FIRST NAME KIM

MIDDLE NAME DELA CRUZ

3. DATE OF BIRTH
(mm/dd/yyyy)
16. CITIZENSHIP Filipino
02/10/1986

4. PLACE OF BIRTH LINGAYEN,PANGASINAN If holder of dual citizenship, Pls. indicate country:

please indicate the details.
5. SEX FEMALE PHILIPPINES

6 CIVIL STATUS MARRIED

17. RESIDENTIAL ADDRESS #44 P.MORAN WEST
House/Block/Lot No. Street
POBLACION
Subdivision/Village Barangay
7. HEIGHT (m) 1.61m LINGAYEN PANGASINAN
City/Municipality Province
8. WEIGHT (kg) 62kg ZIP CODE 2401

9. BLOOD TYPE B
18. PERMANENT ADDRESS #44 P.MORAN WEST
House/Block/Lot No. Street

10. GSIS ID NO. 2004867616 POBLACION

Subdivision/Village Barangay
LINGAYEN PANGASINAN
11. PAG-IBIG ID NO. 12005649686
City/Municipality Province

12. PHILHEALTH NO. 152255000001 ZIP CODE 2401

13. SSS NO. 0225322013 19. TELEPHONE NO. N/A

14. TIN NO. 410-250-552-000 20. MOBILE NO. 09464650568

15. AGENCY EMPLOYEE NO. NR2013-3514 21. E-MAIL ADDRESS (if any) N/A

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME SISON 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
N/A
FIRST NAME ROBERTO ROBERT JOHN DELA CRUZ SISON 6/20/2014

MIDDLE NAME SISON

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME DELA CRUZ

N/A
FIRST NAME BEN(DECEASED)

MIDDLE NAME BARROGA

25. MOTHER'S MAIDEN NAME

SURNAME FERNANDEZ

FIRST NAME ASELA

MIDDLE NAME MACALANDA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ST.COLUMBAN'S COLLEGE
ELEMENTARY PRIMARY EDUCATION 6/15/1993 3/30/1999 N/A 1999 N/A
LINGAYEN,PANGASINAN
PANGASINAN NATIONAL HIGH SCHOOL
SECONDARY
VOCATIONAL / HIGH SCHOOL 6/5/1999 4/5/2003 N/A 2003 N/A
LINGAYEN,PANGASINAN

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

TRADE
LYCEUM-NORTHWESTERN UNIVERSITY BS TOURISM HOTEL & RESTAURANT
COURSE
COLLEGE 6/6/2003 4/5/2007 GRAD 2007 N/A
DAGUPAN CITY MANAGEMENT

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A

(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

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

1/1/2020

(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 not (Write in SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)
GENERAL SERVICE OFFICE
1/1/2020 prsent ADM.AIDE/UTILITY WORKER 503.09/D CASUAL Y
LINGAYEN, PANGASINAN
GENERAL SERVICE OFFICE
10/1/2019 12/1/2019 ADM.AIDE/UTILITY WORKER 503.09/D CASUAL Y
LINGAYEN, PANGASINAN
GENERAL SERVICE OFFICE
7/1/2019 9/30/2019 ADM.AIDE/UTILITY WORKER 503.09/D CASUAL Y
LINGAYEN, PANGASINAN
GENERAL SERVICE OFFICE
1/1/2019 06/030/2019 ADM.AIDE/UTILITY WORKER 503.09/D CASUAL Y
LINGAYEN, PANGASINAN
GENERAL SERVICE OFFICE
7/1/2018 12/31/2018 ADM.AIDE/UTILITY WORKER 477.72/D CASUAL Y
LINGAYEN, PANGASINAN
GENERAL SERVICE OFFICE
1/1/2018 6/30/2018 ADM.AIDE/UTILITY WORKER 477.72/D CASUAL Y
LINGAYEN, PANGASINAN
GENERAL SERVICE OFFICE
10/1/2017 12/31/2017 ADM.AIDE/UTILITY WORKER 453.68/D CASUAL Y
LINGAYEN, PANGASINAN
GENERAL SERVICE OFFICE
7/1/2017 9/30/2017 ADM.AIDE/UTILITY WORKER 453.68/D CASUAL Y
LINGAYEN, PANGASINAN
GENERAL SERVICE OFFICE
1/1/2017 6/30/2017 ADM.AIDE/UTILITY WORKER 453.68/D CASUAL Y
LINGAYEN, PANGASINAN
GENERAL SERVICE OFFICE
10/1/2016 12/31/2017 ADM.AIDE/UTILITY WORKER 430.81/D CASUAL Y
LINGAYEN, PANGASINAN
GENERAL SERVICE OFFICE
8/1/2016 9/30/2016 ADM.AIDE/UTILITY WORKER 430.81/D CASUAL Y
LINGAYEN, PANGASINAN
GENERAL SERVICE OFFICE
7/1/2016 7/31/2016 ADM.AIDE/UTILITY WORKER 430.81/D CASUAL Y
LINGAYEN, PANGASINAN
GENERAL SERVICE OFFICE
6/1/2016 6/30/2016 ADM.AIDE/UTILITY WORKER 430.81/D CASUAL Y
LINGAYEN, PANGASINAN
GENERAL SERVICE OFFICE
1/16/2016 5/31/2016 ADM.AIDE/UTILITY WORKER 409.09/D CASUAL Y
LINGAYEN, PANGASINAN
GENERAL SERVICE OFFICE CONTRACT OF
1/1/2016 1/15/2016 ADM.AIDE/UTILITY WORKER 490.91/D N
LINGAYEN, PANGASINAN SERVICE
GENERAL SERVICE OFFICE CONTRACT OF
7/1/2015 12/31/2015 ADM.AIDE/UTILITY WORKER 490.91/D N
LINGAYEN, PANGASINAN SERVICE
GENERAL SERVICE OFFICE CONTRACT OF
1/1/2015 6/30/2015 ADM.AIDE/UTILITY WORKER 490.91/D N
LINGAYEN, PANGASINAN SERVICE
GENERAL SERVICE OFFICE CONTRACT OF
1/1/2014 12/31/2014 ADM.AIDE/UTILITY WORKER 490.91/D N
LINGAYEN, PANGASINAN SERVICE
GENERAL SERVICE OFFICE CONTRACT OF
7/1/2013 12/31/2013 ADM.AIDE/UTILITY WORKER 490.91/D N
LINGAYEN, PANGASINAN SERVICE
CONTRACT OF
1/1/2012 5/31/2012 OPERATOR NANOX PHIL.INC. CLARK PAMPANGA 315/D N
SERVICE
CONTRACT OF
3/25/2011 12/31/2011 OPERATOR NANOX PHIL.INC. CLARK PAMPANGA 315/D N
SERVICE
CONTRACT OF
1/28/2008 12/31/2008 HOUSEKEEPING BAGUIO COUNRTY CLUB BAGUIO CITY 250/D N
SERVICE

(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 Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS
NUMBER OF HOURS ( Managerial/ Supervisory/
CONDUCTED/SPONSORED
(Write in full) (mm/dd/yyyy) Technical/etc) BY (Write in full)
From To
Human Resource Management
ACTION PLANNING ON PREVENTIVE MAINTENANCE 6/16/2017 8 HOURS MANAGERIAL Development Office
Human Resource Management
PUBLIC SERVICE & EFFECTIVE CLIENT RELATIONSHIP 6/23/2015 6/24/2015 16 HOURS MANAGERIAL Development Office
Human Resource Management
ORIENTATION ON VALUES DEVELOPMENT SEMINAR 8/5/2013 8/6/2013 16 HOURS MANAGERIAL Development Office

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32.
(Write in full)

TUG OF WAR N/A

VOLLEYBALL

HOUSEKEEPING

(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:
________________________________
N/A
________________________________
35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
N/A
________________________________
b. Have you been criminally charged before any court?
If YES, give details:
________________________________
Date Filed: N/A
________________________________
Status of Case/s: N/A

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:
________________________________
N/A
________________________________
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? ________________________________
N/A
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? N/A
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: N/A
39. Have you acquired the status of an immigrant or permanent resident of another country?
If YES, give details (country):
N/A
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: N/A
b. Are you a person with disability?
If YES, please specify ID No: N/A
c. Are you a solo parent?
If YES, please specify ID No: N/A

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

ID picture taken within

NAME ADDRESS TEL. NO. the last 6 months
3.5 cm. X 4.5 cm
MR. MODESTO OPERANIA URBIZTONDO, PANGASINAN N/A (passport size)

With full and handwritten

BAYBAY LOPEZ BINMALEY name tag and signature over
COL. ROMEO AQUINO N/A
PANGASINAN printed name

Computer generated
MR. RONALD GALANG BAGUIO CITY N/A
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: OFFICE ID
ID/License/Passport No.: NR2013-3514 Signature (Sign inside the box)

Date/Place of Issuance: January 11, 2018 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