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 MORENO
NAME EXTENSION (JR., SR)
FIRST NAME MARIE SHELLA

MIDDLE NAME RODELAS

3. DATE OF BIRTH
(mm/dd/yyyy) 8/28/1998 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH SAN PABLO CITY LAGUNA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS 389 PUROK 6
Widowed Separate House/Block/Lot No. Street
Other/s: d BARANGAY STA. MARIA
Subdivision/Village Barangay
SAN PABLO CITY LAGUNA
7. HEIGHT (m) 1.49
City/Municipality Province
8. WEIGHT (kg) 43 ZIP CODE 4000

18. PERMANENT ADDRESS 389 PUROK 6

9. BLOOD TYPE A+
House/Block/Lot No. Street
BARANGAY STA. MARIA
10. GSIS ID NO. N/A
Subdivision/Village Barangay
SAN PABLO CITY LAGUNA
11. PAG-IBIG ID NO. 121280051657
City/Municipality Province

12. PHILHEALTH NO. 08-026733396-7 ZIP CODE 4000

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

14. TIN NO. 774-461-142-000 20. MOBILE NO. 0950-201-7189

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]
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) N/A
FIRST NAME 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 MORENO

NAME EXTENSION (JR., SR)
FIRST NAME MARLON

MIDDLE NAME HERNANDEZ

25. MOTHER'S MAIDEN NAME

SURNAME RODELAS

FIRST NAME MYLA

MIDDLE NAME FANDIALAN (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

1ST HONORABLE
ELEMENTARY STA.MARIA ELEMENTARY SCHOOL PRIMARY GRADUATE 2005 2011 N/A 2011 MENTION

SECONDARY /
VOCATIONAL SANTISIMO ROSARIO NATIONAL HIGHSCHOOL SECOINDARY 2011 2015 N/A 2015 5TH HONOR

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

TRADE
LAGUNA STATE POLYTECHNIC UNIVERSITY SAN ISKOLAR NG
COURSE
COLLEGE BACHERLOR OF SCIENCE IN CRIMINOLOGY 2015 2019 N/A 2019
PABLO CITY CAMPUS BAYAN

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

(Continue on separate sheet if necessary)

SIGNATURE DATE 6/9/2021

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

REGISTERED CRIMINOLOGIST 0.8 NOV 30-DEC 1, 2019 LUCENA QUEZON PROVINCE 0202923 8/28/2023

(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)

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

(Continue on separate sheet if necessary)

SIGNATURE DATE 06/09/2021

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)

N/A
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) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To

CRIMINOLOGY OJT AT PHLIPPINE NATIONAL POLICE 4/15/2019 5/13/2019 97 PHILIPPINE NATIONAL POLICE SPC STATION

CRIMINOLOGY OJT AT PAROLE AND PROBATION OFFICE 3/18/2019 3/28/2019 64

CRIMINLOGY OJT AT BUREAU OF FIRE PROTECTION 2/18/2019 3/7/2019 126

BASIC WATER SAFETY SURVIVAL 5/3/2018 5/3/2018 4

BUREAU OF FIRE PROTECTION BAGUIO

ARREST CONTROL AND HANDCUFFING TECHNIQUE WITH MARTIAL ARTS 5/12/2018 5/12/2018 4
CORDILLERA CAREER DEVELOPMENT COLLEGE

DIGITAL FORENSICS 5/12/2018 5/12/2018 4

UNIVERSITY OF CORDILLERA

BSIC FIRE ARM ORIENTATION 5/11/2018 5/11/2018 4

KINGS COLLEGE LA TRINIDAD

ACTUAL EXAMINATION OF FORENSIC DOCUMENT AND ITS LEAGAL APPLICATION IN COURT 4/25/2018 4/25/2018 8
PHILIPPINE PUBIC SAFETY COLLEGE

SEMINAR ON FIRE DRILL AND FIRE BRIGADE 3/15/2018 3/15/2018 4

BUREAU OF FIRE PROTECTION SPC

ENGLISH SKILLS AND EMPLOYABLITY SKILLS TRAINING PROGRAM 9/1/2017 9/1/2017 24

WORLDWIDE LINK EDUC.DEV.INC.

HANDCUFFING TECHNIQUE AND CRIME SCENE INVESTIGATION 5/10/2017 5/10/2017 4

PHILIPPINE NATIONAL POLICE
SEMI
NAR

MEMB
ERSHI
VIII. P IN
ASSOC
OT IATION
HE
(Continue on separate sheet if necessary) /ORGA
R NIZATI
ON
INF
OR
MA31. SPECIAL SKILLS and HOBBIES 32.
NON-ACADEMIC DISTINCTIONS / RECOGNITION
(Write in full)
TIO
N
(Write
in full)

(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? YES
b. within the fourth degree (for Local Government Unit - Career Employees)? YES
If YES, give details:
________________________________

35. a. Have you ever been found guilty of any administrative offense? YES NO
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court? YES NO
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
YES NO
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, YES NO
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? ________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
YES NO
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last YES NO
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?
YES NO
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? YES NO
If YES, please specify:
b. Are you a person with disability? YES NO
If YES, please specify ID No:
c. Are you a solo parent? YES NO
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
4.5 cm. X 3.5 cm
(passport size)

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 agree that any misrepresentation made in this document and its attachments shall cause the filing of PHOTO
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 Administering Oath

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