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 YSUON
NAME EXTENSION (JR., SR)
FIRST NAME JACOB

MIDDLE NAME AGUSTIN

3. DATE OF BIRTH
12/23/1999 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
✘
by by
birth naturalization
4. PLACE OF BIRTH PADUL SOLANA, CAGAYAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS ZONE 4

House/Block/Lot No. Street
Widowe Separat
SAMPAGUITA
dOther/s: ed
Subdivision/Village Barangay
SOLANA CAGAYAN
7. HEIGHT (m) 5'7
City/Municipality Province
8. WEIGHT (kg) 65 ZIP CODE 3503

18. PERMANENT ADDRESS ZONE 4

9. BLOOD TYPE O+
House/Block/Lot No. Street
SAMPAGUITA
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121342779273 SOLANA CAGAYAN

City/Municipality Province

12. PHILHEALTH NO. 06-250361940-2 ZIP CODE 3503

13. SSS NO. 01-3279835-8 19. TELEPHONE NO. N/A

14. TIN NO. 650-839-432 20. MOBILE NO. 09161017186

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME YUSON 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME LHOVELY

NAME EXTENSION (JR., SR)
COLYNE SOLIVA YUSON 06/28/19

MIDDLE NAME SOLIVA

OCCUPATION N/A

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME YUSON

NAME EXTENSION (JR., SR)
FIRST NAME DENNIS

MIDDLE NAME NALICA

25. MOTHER'S MAIDEN NAME

SURNAME AGUSTIN

FIRST NAME MARIBEL

MIDDLE NAME SAGALON (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY SAMPAGUITA WEST CENTAL SCHOOL 2005 2012 2012

SECONDARY SAMPAGUITA NATIONAL HIGH SCHOOL 2012 2018 2018

VOCATIONAL /

N/A
TRADE
COURSE
COLLEGE CAGAYAN STATE UNIVERSITY BS CRIMINOLOGY 2019 2023 2023

GRADUATE STUDIES N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE October 17, 2024

CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY
27. LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER RATING DATE OF
SPECIAL LAWS/ CES/ CSEE (If Applicable) EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT NUMBER Date of
Validity

Registered Crimonologist 78.1 2/1/2024 Tuguegarao Annafunan Integrated School 0265548 12/23/2027

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

(Continue on separate sheet if necessary)

SIGNATURE DATE OCTOBER 17, 2024

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

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
INCLUSIVE DATES OF
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE Type of LD
NUMBER OF HOURS
( Managerial/ CONDUCTED/ SPONSORED BY
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

ON THE JOB TRAINING AT BUREAU OF FIRE PROTECTION 10,03,2022 11,16,2022 112.0 TUAO FIRE STATION

ON THE JOB TRAINING AT PNP TUAO POILCE STATION 11,21,2022 12,21,2022 104.0
TUAO POLICE STATION
ON THE JOB TRAINING AT BUREAU OF FIRE PROTECTION 02,28,2023 04,04,2023 96.0
PIAT FIRE STATION

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. NON-ACADEMIC DISTINCTIONS / RECOGNITION (Write in full) 33. (Write in
full)

Playing basketball

COOKING

Playing chess

Proficiency in office equipments

Proficiency in computer software and

hardwares

(Continue on separate sheet if necessary)

SIGNATURE DATE OCTOBER 17, 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? 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
by any court or tribunal? YES ✘ NO
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 YES ✘ NO
out (abolition) in the public or private sector? If YES, give details:
________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? YES ✘ NO
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
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
MACKY MIGUEL MINANGA PIAT CAGAYAN 9265241395 4.5 cm. X 3.5 cm
(passport size)

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 me. 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: PRC

ID/License/Passport No.: 0265548

Signature (Sign inside the box)

Date/Place of Issuance: Tuguegarao City, Cagayan

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