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

MIDDLE NAME FORCADAS

3. DATE OF BIRTH
(mm/dd/yyyy) DECEMBER 18,1997 16. CITIZENSHIP

4. PLACE OF BIRTH BAGUMBAYAN ROXAS ORIENTAL MINDORO If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX

17. RESIDENTIAL ADDRESS STA.FE

6 CIVIL STATUS
House/Block/Lot No. Street
BAGUMBAYAN
Subdivision/Village Barangay
ROXAS OERIENTAL MINDORO
7. HEIGHT (m) 1.63
City/Municipality Province
8. WEIGHT (kg) 58 ZIP CODE 5212

18. PERMANENT ADDRESS STA.FE

9. BLOOD TYPE O
House/Block/Lot No. Street
BAGUMBAYAN
10. GSIS ID NO. N/A
Subdivision/Village Barangay
ROXAS ORIENTAL MINDORO
11. PAG-IBIG ID NO. 121228240668
City/Municipality Province

12. PHILHEALTH NO. 09-251856590-9 ZIP CODE 5212

13. SSS NO. 0440544333 19. TELEPHONE NO. N/A

14. TIN NO. 734-300-512 20. MOBILE NO. 09151162502 / 09486697524

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) johnmichaelmortel34@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)
NAME EXTENSION (JR., SR)
FIRST NAME N/A N/A

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME MORTEL

FIRST NAME DANTE SR.

MIDDLE NAME FORTU

25. MOTHER'S MAIDEN NAME

SURNAME FORCADAS

FIRST NAME ESTELITA

MIDDLE NAME FRADEJAS (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
HONORS
(Write in full)
full) (if not graduated) RECEIVED
From To

ELEMENTARY ROXAS CENTRAL SCHOOL 2004 2010 2010

SECONDARY /
VOCATIONAL DANGAY NATIONAL HIGH SCHOOL 2010 2014 2014

N/A

TRADE
BACHELOR OF SECONDARY
COURSE
COLLEGE JOHN PAUL COLLEGE 2014 2018 2018
EDUCATION

GRADUATE STUDIES

(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 SPECIAL DATE OF LICENSE (if applicable)
RATING
LAWS/ CES/ CSEE BARANGAY EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity

LICENSED PROFESSIONAL TEACHER 76.6 2/10/2022 CALAPAN CITY

(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.
28. INCLUSIVE DATES
DEPARTMENT/AGENCY/ GOV'T
(mm/dd/yyyy) POSITION TITLE STATUS
OFFICE/ COMPANY Monthly Salary
APPOINTMENT
SERVICE
(Write in full/Do not abbreviate) (Y/N)
(Write in full/Do not abbreviate)
From To

AUGUST
MARCH 14,2019
15,2019
STORE CREW GOLDILOCKS 9000.00 CONTRACTUAL NO
SEPTEMBER 12, DECEMBER 20
2019 2019
CALL CENTER AGENT INSPIRO 12000.00 CONTRACTUAL NO
NOVEMBER
MARCH 14,2020
30,2020
FIELD MARKETING REPRESENTATIVE ROPALI 9000.00 CONTRACTUAL NO
JANUARY 28 OCTOBER COUNTRY FUNDERS
2021 31,2022
FIELD TRUTH VERIFIER 10400.00 CONTRACTUAL NO
FINANCE CORPORATION

(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

(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 ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)
(Write in full)

COMPUTER LITERATE ATHLETIC AWARD (PRISAA)

(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
chief of bureau authority,
or office orortotothe
theperson who has immediate
supervision over you inwhere
Bureau or Department the Office,
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, If YES, give details:
termination, end of term, finished contract or phased 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 If YES, give details:
a national or local candidate?
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
a.
2000 (RA 8972), please answer the following items:
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
3.5 cm. X 4.5 cm
JELLAR FABITO FERNANDO BONGABONG 9306990456 (passport size)

With full and handwritten

CHARLIE BINARAO ORTIGAS 9973484039 name tag and signature over
printed name

JONNA MAE TAYTAY ROXAS MINDORO 9562710709 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 PHOTO
agree that any misrepresentation made in this document and its attachments shall
cause the filing of administrative/criminal case/s against me.
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 Adminestering Oath

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