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 GASPAR
NAME EXTENSION (JR., SR) N/A
FIRST NAME JAY

MIDDLE NAME FERNANDO

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 06/25/1984
FILIPINO
4. PLACE OF BIRTH ZAMBOANGA CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX MALE PHILIPPINES
17. RESIDENTIAL ADDRESS DON ALFARO STREET, ALVAREZ DRIVE
6 CIVIL STATUS SINGLE
House/Block/Lot No. Street
1400 ROSA VILLAGE PASONANCA
Subdivision/Village Barangay
ZAMBOANGA CITY ZAMBOANGA DEL SUR
7. HEIGHT (m) 5'3
City/Municipality Province
8. WEIGHT (kg) 65 ZIP CODE 7000
18. PERMANENT ADDRESS DON ALFARO STREET, ALVAREZ DRIVE
9. BLOOD TYPE B+
House/Block/Lot No. Street
1400 ROSA VILLAGE PASONANCA
10. GSIS ID NO. N/A
Subdivision/Village Barangay
ZAMBOANGA CITY ZAMBOANGA DEL SUR
11. PAG-IBIG ID NO.
City/Municipality Province

12. PHILHEALTH NO. ZIP CODE 7000

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 20. MOBILE NO.

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 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 GASPAR

NAME EXTENSION (JR., SR)
FIRST NAME JAIME

MIDDLE NAME HERNANDO

25. MOTHER'S MAIDEN NAME

SURNAME FERNANDO

FIRST NAME CAMILA

MIDDLE NAME BAUTISTA (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 TETUAN ELEMENTARY SCHOOL ELEMENTARY Jun-95 Mar-97 N/A 1997 N/A

SECONDARY /
VOCATIONAL ATENEO DE ZAMBOANGA HIGH SCHOOL Jun-97 Mar-01 N/A 2001 N/A

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

TRADE
COURSE
COLLEGE WESTERN MINDANAO STATE UNIVERSITY BACHELOR OF SCIENCE IN NURSING Jun-01 Mar-05 N/A 2005 N/A

GRADUATE STUDIES WESTERN MINDANAO STATE UNIVERSITY MASTERS OF ARTS IN NURSING N/A N/A 3 units N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE 03/10/2020

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

(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)
03/28/2019 Present JOB-ORDER (SHE Program) CITY GOVERNMENT OF ZAMBOANGA N/A CONTRACTUAL YES

PASTOR BONUS SEMINARY, ZAMBOANGA

06/03/2013 02/28/2019 SCHOOL REGISTRAR N/A PERMANENT NO
CITY
PASTOR BONUS SEMINARY, ZAMBOANGA
06/01/2011 05/31/2013 SCHOOL SECRETARY N/A PERMANENT NO
CITY
NOTRE DAME OF SIENA SCHOOL OF
05/03/2010 12/3/2010 DATA ENCODER N/A CONTRACTUAL NO
MARBEL, KORONADAL CITY
 (Continue on separate sheet if necessary)
SIGNATURE DATE 01/15/2020
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

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

REGIONAL SUMMIT-WRITESHOP ON THE HARMONIZATION OF HIGHER COMMISSION ON HIGHER EDUCATION

04/13/2015 04/14/2015 16 TECHNICAL
EDUCATION RECORDS ON SPECIAL ORDER REGION IX
FORUM ON DISASTER RISK REDUCTION AND MANAGEMENT: CHALLENGES AND
02/28/2015 02/28/2015 8 TECHNICAL WESTERN MINDANAO STATE UNIVERSITY
POLICY DIRECTIONS
HIGHER EDUCATION MANAGEMENT INFORMATION SYSTEM WRITESHOP /
COMMISSION ON HIGHER EDUCATION
ORIENTATION (HEMIS) CLUSTER VALIDATION AND FINAL UPLOADING TO THE 08/19/2014 08/20/2014 16 TECHNICAL
REGION IX
CHECK SYSTEM
HIGHER EDUCATION MANAGEMENT INFORMATION SYSTEM WRITESHOP / COMMISSION ON HIGHER EDUCATION
07/15/2014 07/18/2014 32 TECHNICAL
ORIENTATION (HEMIS) WRITESHOP / ORIENTATION REGION IX
HIGHER EDUCATION DATA VALIDATION AND CHED ELECTRONIC COLLECTION
COMMISSION ON HIGHER EDUCATION
(CHECK) SYSTEM HANDS-ON ACTIVITY TO ALL COLLEGE REGISTRARS AND MIS 11/20/2013 11/20/2013 8 TECHNICAL
REGION IX
OFFICERS
ANNUAL REGISTRAR'S AND MIS OFFICERS ORIENTATION TRAINING AND COMMISSION ON HIGHER EDUCATION
07/29/2013 07/31/2013 24 TECHNICAL
HIGHER DATA COLLECTION REGION IX
ZAMBOANGA BASILAN SULU TAWI-TAWI
ASSOCIATION OF PRIVATE SCHOOLS
2010 GENERAL ASSEMBLY 10/08/2010 10/08/2010 8 TECHNICAL (ZAMBASULTAPS) AND CATHOLIC
EDUCATIONAL ASSOCIATION OF THE
PHILIPPINES
HIGHER EDUCATION MANAGEMENT INFORMATION SYSTEM WRITESHOP / COMMISSION ON HIGHER EDUCATION
07/05/2010 07/08/2010 32 TECHNICAL
ORIENTATION (HEMIS) WRITESHOP / ORIENTATION REGION IX

(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 ZAMBOANGA HERMOSA CHORALE

SURFING THE INTERNET CORO IMMACULADA CONCEPCION

MCIC LECTORS AND COMMENTATORS

SINGING N/A
MINISTRY
MOTHER BUTLER MISSION GUILDS

(Continue on separate sheet if necessary)

SIGNATURE DATE 01/15/2020

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:
________________________________
________________________________
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, termination, end of term, finished contract or phased If YES, give details:
out (abolition) in the public or private sector? TERMINATION
________________________________
________________________________
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 a national or local candidate? If YES, give details:
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 2000 (RA 8972), please answer the following items:
a. 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
PUTIK-LUNZURAN ROAD, ZAMBOANGA the last 6 months
FISCAL RICARDO CABARON CITY
09175566042 3.5 cm. X 4.5 cm
(passport size)

DR. JULIET D. RUSTE GOVERNOR CAMINS, ZAMBOANGA CITY 09173059884 With full and handwritten
name tag and signature over
printed name
MR. ARTURO CABIDOG, JR. GUIWAN, ZAMBOANGA CITY 09066648613
Computer generated
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.
or photocopied picture
is not acceptable

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: PASSPORT

ID/License/Passport No.: EC8132365

Signature (Sign inside the box)
 01/15/2020
Date/Place of Issuance: 06/26/2016 ZAMBOANGA CITY
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