PDS (Revised 2005)

CS FORM 212 (Revised 2005)
PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes
q with "P " and use separate sheet if necessary.
1. CS ID No.
(to be filled up by CSC)
I. PERSONAL INFORMATION
2. SURNAME FIRST NAME MIDDLE NAME
M/A/N/L/U/T/A/C B/R/I/L/L/I/A/N/T E/N/R/I/Q/U/E/Z 11/21/1983 Mabalacat, Pampanga

ZIP CODE Widowed Single Married Separat 17. TELEPHONE NO. Annulled ed Others, specify ___________ 18. PERMANENT ADDRESS 16. RESIDENTIAL ADDRESS
4. DATE OF BIRTH (mm/dd/yyyy) 5. PLACE OF BIRTH 6. SEX 7. CIVIL STATUS
1081 Pasig Candaba, Pampanga
8. CITIZENSHIP 9. HEIGHT (m)
Male
Filipino 1.68 m 60 kg B+ n/a n/a n/a n/a n/a n/a n/a
ale Fem
2013 1081 Pasig Candaba, Pampanga 2013 n/a
brilliantmanlutac@yahoo.com
10. WEIGHT (kg)
ZIP CODE 19. TELEPHONE NO. 20. E-MAIL ADDRESS (if any) 21. CELLPHONE NO. (if any) 22. AGENCY EMPLOYEE NO.
11. BLOOD TYPE
12. GSIS ID NO.
n/a 1400-0121-7101 n/a
13. PAG-IBIG ID NO.
0909-2018-627
14. PHILHEALTH NO.
15. SSS NO.
23. TIN
II. FAMILY BACKGROUND

24.SPOUSE'S SURNAME FIRST NAME MIDDLE NAME OCCUPATION EMPLOYER/BUS. NAME BUSINESS ADDRESS TELEPHONE NO. 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
n/a 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)
26. FATHER'S SURNAME FIRST NAME MIDDLE NAME 27. MOTHER'S MAIDEN NAME SURNAME FIRST NAME MIDDLE NAME
MANLUTAC ALEX GUMABON ENRIQUEZ TONA YUZON

YEAR GRADUATED DEGREE COURSE (Write in full)
10/30/1960 / / / /
12/07/1962 / / (Continue on separate sheet if necessary) HIGHEST GRADE/ LEVEL/ UNITS EARNED (if not graduated) / /
III. EDUCATIONAL BACKGROUND

28. LEVEL NAME OF SCHOOL (Write in full)
INCLUSIVE DATES OF ATTENDANCE From To
SCHOLARSHIP/ ACADEMIC HONORS RECEIVED
ELEMENTARY
Candaba Central Elementary School
(if graduated) 1995
1989 1995
1995 1999
SECONDARY VOCATIONAL /
Holy Cross College n/a
1999 Bachelor of Science in Criminolog y Bachelor of Laws
COLLEGE COURSE
TRADE
Angeles University Foundation
2003
1999
2003
GRADUATE STUDIES
Harvadian Colleges
2010
Present
(Continue on separate sheet if necessary) Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY

29. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEE RATING DATE OF EXAMINATION / CONFERMENT LICENSE (if applicable) PLACE OF EXAMINATION / CONFERMENT NUMBER DATE OF RELEASE
V. WORK EXPERIENCE (Include private employment. Start from your current work)
30. INCLUSIVE DATES (mm/dd/yyyy) From To POSITION TITLE (Write in full) DEPARTMENT / AGENCY / OFFICE / COMPANY (Write in full)
MONTHLY SALARY
SALARY GRADE & STATUS OF STEP APPOINTMEN INCREMENT T (Format "000")
GOV'T SERVICE
(Yes / No)
/ / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /
/ / / / / / / /
/ / / / / / / / / / / /
/ / / / / / / / / / / /
(Continue on separate sheet if necessary) CS FORM 212 (Revised 2005), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

INCLUSIVE DATES 31. NAME & ADDRESS OF ORGANIZATION (Write in full) (mm/dd/yyyy) From To NUMBER OF HOURS POSITION / NATURE OF WORK
/ / / / /
/ / / / /
/ / / / /
/ / / / /
VII. TRAINING PROGRAMS (Start from the most recent training.)

32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write in full) INCLUSIVE DATES OF ATTENDANCE From (mm/dd/yyyy) To NUMBER CONDUCTED/ SPONSORED BY OF HOURS (Write in full)
/ / / / / /
/ / / /
/ / / / / /
/ /
/ / / / / /
/ /
/ / / / / /
VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION: 33. SPECIAL SKILLS / HOBBIES: 34. (Write in full) 35.
MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full)
(Continue on separate sheet if necessary) CS FORM 212 (Revised 2005), Page 3 of 4
36. Are
you related by consanguinity or affinity to any of the following :
a. Within
the third degree (for National Government Employees): appointing authority, recommending authority, chief of office/bureau/department or person who has immediate supervision over you in the Office, Bureau or Department where you will be appointed? the fourth degree (for Local Government Employees): appointing authority or recommending authority where you will be appointed?
b. Within
37 a.
Have you ever been formally charged?
b. Have you ever been guilty of any administrative offense?
38. Have
you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal?
39. 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, AWOL or phased out, in the public or private sector?
40. Have
you ever been a candidate in a national or local election (except Barangay election)?
41. 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: Are you a member of any indigenous group? Are you differently abled? Are you a solo parent?
a. b. c.
42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee) NAME ADDRESS
YES YES YES YES YES YES YES YES YES YES
If YES, give details: ____________________________________ _ ____________________________________ _ ____________________________________ _ If YES, give details: ____________________________________ _ ____________________________________ _ ____________________________________ If _ YES, give details: ________________________________ ________________________________ If YES, give details: ________________________________ ________________________________ If YES, give details: ________________________________ ________________________________ If YES, give details: ________________________________ ________________________________ If YES, give details: ________________________________ ________________________________
TEL. NO.
ID picture taken within the last 6 months 3.5 cm. X 4.5 cm (passport size) Computer generated or xerox copy of picture is not acceptable
If YES, please specify: ____________________ If YES, please specify: ____________________ If YES, please specify: ____________________
43. I
declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust that this information shall remain confidential.
PHOTO
COMMUNITY TAX CERTIFICATE NO.
ISSUED AT
SIGNATURE (Sign inside the box)
ISSUED ON (mm/dd/yyyy)
DATE ACCOMPLISHED
RIGHT THUMBMARK
CS FORM 212 (Revised 2005), Page 4 of 4

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PDS (Revised 2005)

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CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

q with "P " and use separate sheet if necessary.

(to be filled up by CSC)

M/A/N/L/U/T/A/C B/R/I/L/L/I/A/N/T E/N/R/I/Q/U/E/Z 11/21/1983 Mabalacat, Pampanga

4. DATE OF BIRTH (mm/dd/yyyy) 5. PLACE OF BIRTH 6. SEX 7. CIVIL STATUS

1081 Pasig Candaba, Pampanga

8. CITIZENSHIP 9. HEIGHT (m)

10. WEIGHT (kg)

11. BLOOD TYPE

12. GSIS ID NO.

n/a 1400-0121-7101 n/a

13. PAG-IBIG ID NO.

14. PHILHEALTH NO.

15. SSS NO.

II. FAMILY BACKGROUND

n/a 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)

MANLUTAC ALEX GUMABON ENRIQUEZ TONA YUZON

III. EDUCATIONAL BACKGROUND

INCLUSIVE DATES OF ATTENDANCE From To

SCHOLARSHIP/ ACADEMIC HONORS RECEIVED

Candaba Central Elementary School

(if graduated) 1995

Holy Cross College n/a

1999 Bachelor of Science in Criminolog y Bachelor of Laws

Angeles University Foundation

(Continue on separate sheet if necessary) Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY

(Continue on separate sheet if necessary)

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

(Continue on separate sheet if necessary)

VII. TRAINING PROGRAMS (Start from the most recent training.)

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full)

(Continue on separate sheet if necessary) CS FORM 212 (Revised 2005), Page 3 of 4

you related by consanguinity or affinity to any of the following :

Have you ever been formally charged?

b. Have you ever been guilty of any administrative offense?

COMMUNITY TAX CERTIFICATE NO.

SIGNATURE (Sign inside the box)

CS FORM 212 (Revised 2005), Page 4 of 4

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