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 LU
NAME EXTENSION (JR., SR)
FIRST NAME GEENEX ARIES

MIDDLE NAME RAMOS

3. DATE OF BIRTH
4/11/1995 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dualby
Citizenship
birt by naturalization
4. PLACE OF BIRTH QUEZON CITY, METRO MANILA If holder of dual citizenship, h indicate country:
Pls.
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Married 17. RESIDENTIAL ADDRESS #388 PUROK 2

Single House/Block/Lot No. Street
✘ Wido Separate
BARANGAY BAKOD BAYAN
wed
Other/ d Subdivision/Village Barangay
s: CABANATUAN CITY NUEVA ECIJA
7. HEIGHT (m) 1.62m
City/Municipality Province
8. WEIGHT (kg) 65kg ZIP CODE 3100

18. PERMANENT ADDRESS #388 PUROK 2

9. BLOOD TYPE O
House/Block/Lot No. Street
BARANGAY BAKOD BAYAN
10. GSIS ID NO. N/A
Subdivision/Village Barangay
CABANATUAN CITY NUEVA ECIJA
11. PAG-IBIG ID NO. 1211-6611-6100
City/Municipality Province

12. PHILHEALTH NO. 210253256553 ZIP CODE 3100

13. SSS NO. 02-3991287-5 19. TELEPHONE NO. N/A

14. TIN NO. 327049693 20. MOBILE NO. 0916-948-2041

15. AGENCY EMPLOYEE NO. 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 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 LU

NAME EXTENSION (JR., SR)
FIRST NAME ELEUTERIO

MIDDLE NAME MALANAO

25. MOTHER'S MAIDEN NAME

SURNAME RAMOS

FIRST NAME GINA

MIDDLE NAME TABAJONDA (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

ELEMENTARY SACRED HEART OF JESUS MONTESSORI SCHOOL N/A 2001 2007 2007 N/A

SECONDARY /
VOCATIONAL WESLEYAN UNIVERSITY - PHILIPPINES N/A 2007 2011 2011 N/A

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

TRADE
ABE INTERNATIONAL COLLEGE OF BUSINESS AND BACHELOR OF SCIENCE IN TOURISM
COURSE
COLLEGE
ECONOMICS MANAGEMENT
2011 2015 2015 N/A

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE March 25, 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

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

(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)
NUEVA ECIJA EYE AND LASER CENTER
3/15/2017 2/7/2020 PHILHEALTH STAFF 13000.00 REGULAR
INC.
7/1/2016 3/10/2017 TOUR GUIDE JENNY TRAVEL AND TOURS 10000.00 REGULAR

3/10/2016 6/30/2016 TREASURY ASSISTANT ACE HARDWARE PHILIPPINES INC 10000.00 REGULAR

(Continue on separate sheet if necessary)

SIGNATURE DATE 03/25/2021

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)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
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

6/14/2014 9/7/2014 TESDA LANGUAGE SKILLS INSTITUTE

English Proficiency

(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
(Write in full)
full)

COMPUTER LITERATE N/A N/A

COOKING

READING

(Continue on separate sheet if necessary)

SIGNATURE DATE 03/25/2021

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, ✘ NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased YES give details:
If YES,
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 ✘ NO
YES
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
DR. NOEL B MADUCDOC DR. PJGRMRC 9175808228 4.5 cm. X 3.5 cm
(passport size)
NUEVA ECIJA EYE AND LASER CENTER
ALLEN MAE JUAN INC
9365034366
Computer generated
or photocopied picture
AURELIA MERCADO BAKOD BAYAN CABANATUAN CITY 9194501954 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.: 011160913900

Signature (Sign inside the box)
03/25/2021
Date/Place of Issuance: UMID ID
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