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 PERGES
NAME EXTENSION (JR., SR)
FIRST NAME LESYL

MIDDLE NAME MISSION

3. DATE OF BIRTH
(mm/dd/yyyy) 03/13/1998 16. CITIZENSHIP FILIPINO

4. PLACE OF BIRTH MANGA DISTRICT TAGBILARAN CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Female

6 CIVIL STATUS
17. RESIDENTIAL ADDRESS 0025 [email protected]
House/Block/Lot No. Street
Single
N/A MANGA
Subdivision/Village Barangay
TAGBILARAN CITY BOHOL
7. HEIGHT (m) 1.57 (M)
City/Municipality Province
8. WEIGHT (kg) 58 ( kg) ZIP CODE 6300

18. PERMANENT ADDRESS 0025 PUROK

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

11. PAG-IBIG ID NO. N/A

TAGBILARAN CITY BOHOL
City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 6300

13. SSS NO. N/A 19. TELEPHONE NO. NONE

14. TIN NO. 20. MOBILE NO. 09265499033

15. AGENCY EMPLOYEE NO. NONE 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME PERGES

FIRST NAME LEOPOLDO SR.

MIDDLE NAME MARAVILLAS

25. MOTHER'S MAIDEN NAME

SURNAME MISSION

FIRST NAME SOFIA

MIDDLE NAME CALIÑIAHAN (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY MANGA ELEMENTARY SCHOOL GRADUATED N/A N/A N/A 2010-2011 N/A

SECONDARY MANGA NATIONAL HIGH SCHOOL GRADUATED N/A N/A N/A 2015-2020 N/A
VOCATIONAL /

MARIBOJOC ORGANIC DEMO FARMING CENTER NC II ORGANIC AGRICULTURE PRODUCTION N/ A N/A N/A 2020 N/A
TRADE
COURSE
COLLEGE BOHOL ISLAND STATE UNIVERSITY BILAR CAMPUS BACHELOR OF SCIENCE IN AGRICULTURE N/A N/A N/A 2023-2024 N/A

GRADUATE STUDIES NONE

(Continue on separate sheet if necessary)

SIGNATURE DATE January 5, 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

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 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 NOVEMBER 25,2024

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

TUBIGON FEDERATED COUNCIL OF WOMEN 1/12/2013 1/12/2023 TREASURER

TUBIGON WOMEN SLP 2017 RECENT TREASURER

(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 ATTENDANCE

30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS Type of LD
( Managerial/ CONDUCTED/ SPONSORED BY
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS
Supervisory/ (Write in full)
Technical/etc)
From To
MUNICIPAL ROLLOUT TRAINING ON THE ENHANCED PARTICIPATORY BARANGAY 08/22/2023 08/24/2023 24 Hours Department of Social Welfare & Development &
DEVELOPMENT PLANNING Department of Interior and Local Government

KATARUNGANG PAMBARANGAY ENHANCEMENT TRAINING 3/8/2023 4/8/2023 16 Hours Department of Interior and Local Government

(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 NONE NONE

 (Continue on separate sheet if necessary)

SIGNATURE DATE NOVEMBER 25,2024

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?
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 phased
out (abolition) in the public or private sector? If YES, give details:
________________________________
Finished Contract
________________________________

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 items:
a. 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. ID picture taken within

the last 6 months
3.5 cm. X 4.5 cm
RITA AMOR NARVASA CENTRO, TUBIGON, BOHOL 9217959728 (passport size)

With full and handwritten

name tag and signature over
JENNIFER P. AMIHAN LINTUAN, LOON, BOHOL 9998531596 printed name

Computer generated
HENNESSY RAMOS-MUGA UBOJAN, TUBIGON, BOHOL 9091446559 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: Philippine Statistic Authority

ID/License/Passport No.: 5718-0358-9537-4308

Signature (Sign inside the box)
?> NOV. 25,2024
Date/Place of Issuance: 05/26/2022
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.
ENGR. WILLIAM R. JAO
Person Administering Oath

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