CS Form No.

212

PERSONAL DATA SHEET

Revised 2017

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 Galino
NAME EXTENSION (JR., SR) N/A
FIRST NAME Jeffrey

MIDDLE NAME Rivera

3. DATE OF BIRTH
(mm/dd/yyyy)
04/01/1987 16. CITIZENSHIP Filipino Dual Citizenship
by birth by naturalization

4. PLACE OF BIRTH Quezon City If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female

Single Married 17. RESIDENTIAL ADDRESS 2033 Cadena de Amor Street

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
Area B, Camarin 174
Other/s:
Subdivision/Village Barangay
Caloocan City Metro Manila
7. HEIGHT (m) 1.77
City/Municipality Province

8. WEIGHT (kg) 90 ZIP CODE 1400

9. BLOOD TYPE O 18. PERMANENT ADDRESS 2033 Cadena de Amor Street

House/Block/Lot No. Street

10. GSIS ID NO. 2004183006 Area B, Camarin 174

Subdivision/Village Barangay

11. PAG-IBIG ID NO.

Caloocan City Metro Manila
City/Municipality Province

12. PHILHEALTH NO. ZIP CODE 1400

13. SSS NO. 2004183006 19. TELEPHONE NO.

14. TIN NO. 26609950119 20. MOBILE NO. 09291621929

15. AGENCY EMPLOYEE NO. HS - 00866 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

MIDDLE NAME N/A N/A N/A

OCCUPATION N/A N/A N/A

EMPLOYER/BUSINESS NAME N/A N/A N/A

BUSINESS ADDRESS N/A N/A N/A

TELEPHONE NO. N/A N/A N/A

24. FATHER'S SURNAME Galino N/A N/A

FIRST NAME Ernesto

NAME EXTENSION (JR., SR) N/A N/A

MIDDLE NAME Ilaog N/A N/A

25. MOTHER'S MAIDEN NAME N/A N/A

SURNAME Rivera N/A N/A

FIRST NAME Rosanna N/A N/A

MIDDLE NAME Fajardo (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY Camarin Elementary School 1992 1999 1999

SECONDARY Camarin High School 1999 2003 2003

VOCATIONAL /
N/A
TRADE COURSE

DOST /
COLLEGE Philippine Normal University Bachelor of Science in Physics for Teachers 2003 2007 2007
Cum Laude

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE June 8, 2018 CS FORM 212 (Revised 2017), Page 1 of 4