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 ATIENZA
NAME EXTENSION (JR., SR) N/A
FIRST NAME JOHN MARK

MIDDLE NAME DAGOMBOY

3. DATE OF BIRTH
12/18/1993 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH PUERTO PRINCESA CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

Married
17. RESIDENTIAL ADDRESS ZABALLA ST.
6 CIVIL STATUS Single ✘
House/Block/Lot No. Street
Widowed Separate
d TINIGUIBAN
Other/s:
Subdivision/Village Barangay

7. HEIGHT (m) 1.54 Puerto Princesa City Palawan

City/Municipality Province
8. WEIGHT (kg) 72 ZIP CODE 5300

9. BLOOD TYPE A
18. PERMANENT ADDRESS ZABALLA ST.
House/Block/Lot No. Street

10. GSIS ID NO. N/A TINIGUIBAN

Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A Puerto Princesa City Palawan

City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 5300

13. SSS NO. N/A 19. TELEPHONE NO. N/A

14. TIN NO. 20. MOBILE NO. 09950381937

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any)

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME ATIENZA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

NAME EXTENSION (JR., SR)

FIRST NAME RUTH N/A JHAYRHU ETHAN C. ATIENZA 11/25/2015

MIDDLE NAME CABANILLAS

OCCUPATION TEACHER

EMPLOYER/BUSINESS N DEPED

BUSINESS ADDRESS BARANGAY STA. MONICA, PUERTO PRINCESA CITY

TELEPHONE NO. 484338267

24.FATHER'S SURNAME ATIENZA

FIRST NAME AVELINO JR

MIDDLE NAME GILONGOS

25. MOTHER'S MAIDEN NAM TIMBANCAYA

SURNAME ATIENZA

FIRST NAME NELDA

MIDDLE NAME DAGOMBOY (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY
ANDRES SORIANO MEMORIAL ELEMENTARY 2001 2006 Graduated 2006 N/A
ELEMENTARY SCHOOL
VOCATIONAL /
SECONDARY
SAN MIGUEL NATIONAL HIGH HIGH SCHOOL 2006 2010 Graduated 2010 N/A
SCHOOL

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

COLLEGE
WESTERN PHILIPPINES BACHELOR OF SCIENCE IN 2010 2014 Graduated 2014 N/A
TRADE UNIVERSITY CRIMINOLOGY
COURSE
GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE 11/15/2022

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

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.
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 SALARY
applicable)& STEP
APPOINTMENT
(Write in full/Do not abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To (Y/ N)

20217 2022 OWNER BUSSINESS OWNER (FRUITS AND VEGETABLE) N/A N/A NO

*NOTHING FOLLOWS*

(Continue on separate sheet if necessary)

SIGNATURE DATE 07/01/2022

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 NUMBER OF
(Write in full) HOURS POSITION / NATURE OF WORK
(mm/dd/yyyy)
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
(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
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE Type of LD
NUMBER OF ( Managerial/ CONDUCTED/ SPONSORED BY
(Write in full) (mm/dd/yyyy) HOURS Supervisory/ (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

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

COOKING N/A N/A

SINGING

COMPUTER LITERATE

*NOTHING FOLLOWS*

(Continue on separate sheet if necessary)

SIGNATURE DATE 07/01/2022

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 ✘ NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘ NO
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 out (abolition) in YES ✘ NO
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
MR. REGAN ALILI PUERTO PRINCESA CITY 09 3.5 cm. X 4.5 cm
(passport size)

With full and handwritten

PUERTO PRINCESA CITY 09171655502 name tag and signature over
printed name

Computer generated
PUERTO PRINCESA CITY 09127812520 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:

ID/License/Passport No.:
Signature (Sign inside the box)
PUERTO PRINCESA 11/15/2022
Date/Place of Issuance: 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