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 CARREON

FIRST NAME LEENVEN JAMES

MIDDLE NAME CABACABA

3. DATE OF BIRTH
(mm/dd/yyyy) 7/9/2006 16. CITIZENSHIP

4. PLACE OF BIRTH GUIUAN E. SAMAR If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX MALE

17. RESIDENTIAL ADDRESS N/A PUROK 3

6 CIVIL STATUS SINGLE
House/Block/Lot No. Street
LUBO BRGY. 08
Subdivision/Village Barangay
7. HEIGHT (m) 165.5 6809 GUIUAN EASTERN SAMAR
City/Municipality Province
8. WEIGHT (kg) 49 ZIP CODE 6809
18. PERMANENT ADDRESS N/A PUROK 3
9. BLOOD TYPE O
House/Block/Lot No. Street
LUBO BRGY. 08
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A 6809 GUIUAN EASTERN SAMAR

City/Municipality Province
12. PHILHEALTH NO. ZIP CODE 6809
N/A
13. SSS NO. 19. TELEPHONE NO. N/A

14. TIN NO. 20. MOBILE NO. 09855678567

N/A
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)
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 N/A

FIRST NAME N/A

MIDDLE NAME N/A

25. MOTHER'S MAIDEN NAME

SURNAME CABACABA 8/30/1964

FIRST NAME SEGUNDA

MIDDLE NAME LARIDA

III. EDUCATIONAL BACKGROUND
HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
UNITS ACADEMIC
LEVEL (Write in full) EARNED
GRADUATED
HONORS
(Write in full) (if not RECEIVED
From To
graduated)
ELEMENTARY GUIUAN EAST CENTRAL SCHOOL N/A N/A N/A

SECONDARY GUIUAN NATIONAL HIGH SCHOOL HOME ECONOMICS N/A With Honor

VOCATIONAL / TESDA COOKERY NC II

TRADE COURSE

COLLEGE N/A N/A N/A N/A N/A N/A N/A

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

(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/ SERVICE
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY PAY GRADE (if STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To
(Y/ N)

(Continue on separate sheet if necessary)

SIGNATURE DATE
e 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
R (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
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) From To Technical/etc)

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

(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?
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 If YES, give details:
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 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
a.
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.

GUIUAN NATIONAL HIGH SCHOOL

EASTERN SAMAR SATE

UNIVERSITY- GUIUAN

GUIUAN NATIONAL HIGH SCHOOL

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 PHOTO
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 Administering Oath

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