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 EDRIS
KHAIRAH NAME EXTENSION (JR., SR) N/A
FIRST NAME
MIDDLE NAME MAMA
3. DATE OF BIRTH
6-4-2006 16. CITIZENSHIP Filipino Dual Citizenship
(mm/dd/yyyy)
by birth by naturalization
4. PLACE OF BIRTH BUGAWAS D.O.S MAG. If holder of dual citizenship, Pls. indicate country:
Female please indicate the details.
5. SEX Male
6 CIVIL STATUS
Single Married 17. RESIDENTIAL ADDRESS N/A PELICAN STREET
Widowed Separated House/Block/Lot No. Street
FEDERVILLE RH 11
Other/s:
Subdivision/Village Barangay
COTABATO CITY COTABATO
7. HEIGHT (m) 1.60 m
City/Municipality Province
8. WEIGHT (kg) 48 kg ZIP CODE 9600
18. PERMANENT ADDRESS N/A PELICAN STREET
9. BLOOD TYPE N/A
House/Block/Lot No. Street
FEDERVILLE RH 11
10. GSIS ID NO. N/A
Subdivision/Village Barangay
N/A
COTABATO CITY COTABATO
11. PAG-IBIG ID NO.
City/Municipality Province
12. PHILHEALTH NO. N/A ZIP CODE 9600
13. SSS NO. N/A 19. TELEPHONE NO. N/A
14. TIN NO. N/A 20. MOBILE NO. 09059051702
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)
FIRST NAME N/A NAME EXTENSION (JR., SR) N/A 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 EDRIS
HASSAN NAME EXTENSION (JR., SR) N/A
FIRST NAME
MIDDLE NAME EDZLA
25. MOTHER'S MAIDEN NAME
SURNAME MAMA
FIRST NAME RAHIMA
MIDDLE NAME SAID (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
SCHOLARSHIP/
PERIOD OF ATTENDANCE HIGHEST LEVEL/
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE YEAR ACADEMIC
LEVEL UNITS EARNED
GRADUATED HONORS
(Write in full) (Write in full) (if not graduated) RECEIVED
From To
RANK 2
ELEMENTARY L.R. SEBASTIAN ELEMENTARY SCHOOL ELEMENTARY 6-14-2010 4-6-2018 N/A 2018 WITH
HONORS
CSU- UNIVERSITY LABORATORY SCHOOL JUNIOR HIGH SCHOOL
SECONDARY CSU-UNIVERSITY LABORATORY SCHOOL 8-6-2018 6-6-2024 N/A 2024 N/A
SENIOR HIGH SCHOOL
VOCATIONAL /
N/A N/A N/A N/A N/A N/A N/A
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 45357
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL DATE OF LICENSE (if applicable)
RATING
LAWS/ CES/ CSEE BARANGAY EXAMINATION / PLACE OF EXAMINATION / CONFERMENT Date of
(If Applicable) NUMBER
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.
INCLUSIVE DATES SALARY/ JOB/ PAY
28.
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY GRADE (if applicable)& STATUS OF GOV'T SERVICE
(Write in full/Do not abbreviate) (Write in full/Do not abbreviate) SALARY STEP (Format "00-0")/
APPOINTMENT (Y/ N)
From To INCREMENT
N/A N/A N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)
SIGNATURE DATE March 6, 2024
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29.
(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
Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS Supervisory/
(Write in full) (mm/dd/yyyy) (Write in full)
Technical/etc)
From To
N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full) (Write in full)
PUBLIC SPEAKING N/A THE SULTAN TURRET
READING
ORGANIZING
COMPUTER LITERATE
(Continue on separate sheet if necessary)
SIGNATURE DATE March 6, 2024
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? N
YES
O
N
b. within the fourth degree (for Local Government Unit - Career Employees)? YES
O
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 by any
YES NO
court or tribunal? If YES, give details:
________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation, retirement, YES NO
dropped from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in the If YES, give details:
public or private sector? ________________________________
a. Have you ever been a candidate in a national or local election held within the last year (except ________________________________
38. 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
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
RAWAN Y. LANGEBAN COTABATO CITY N/A (passport size)
NORMAINA A. TIBAN COTABATO CITY N/A
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 administrative/criminal case/s against PHOTO
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: N/A
ID/License/Passport No.: N/A
Signature (Sign inside the box)
March 6, 2024
Date/Place of Issuance: N/A
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
