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 DELA CRUZ
NAME EXTENSION (JR., SR)
FIRST NAME JUAN JR
MIDDLE NAME DIMAANO
3. DATE OF BIRTH
(mm/dd/yyyy) 12/30/1991 16. CITIZENSHIP ✘ Filipino DualbyCitizenship
birt by naturalization
4. PLACE OF BIRTH MANILA If holder of dual citizenship,
h
Pls. indicate country:
please indicate the details. Leav
5. SEX ✘ Male Female
✘ Married 17. RESIDENTIAL ADDRESS 06 MAPAYAPA STREET
6 CIVIL STATUS Single
Wido Separate House/Block/Lot No. Street
wed d N/A BRGY. 123
Other/ Subdivision/Village Barangay
s: MANILA METRO MANILA
7. HEIGHT (m) 1.67m
City/Municipality Province
8. WEIGHT (kg) 58kg ZIP CODE 1300

18. PERMANENT ADDRESS 06 MAPAYAPA STREET

9. BLOOD TYPE O+
House/Block/Lot No. Street
N/A BRGY. 123
10. GSIS ID NO. 0123456789
Subdivision/Village Barangay
MANILA METRO MANILA
11. PAG-IBIG ID NO. 0123-4567-8910
City/Municipality Province

12. PHILHEALTH NO. 01-234567891-2 ZIP CODE 1300

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

14. TIN NO. 123-456-789-000 20. MOBILE NO. 09223456789

15. AGENCY EMPLOYEE NO. D12305 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)
NAME EXTENSION (JR., SR)
FIRST NAME N/A

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME DELA CRUZ

NAME EXTENSION (JR., SR)
FIRST NAME JUAN SR
MIDDLE NAME MARASIGAN No. 2

25. MOTHER'S MAIDEN NAME

SURNAME DIMAANO

FIRST NAME LUZVIMINDA

MIDDLE NAME LIWANAG (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY EMILIO JACINTO ELEMENTARY SCHOOL PRIMARY 1998 2004 N/A 2004 N/A

SECONDARY /
VOCATIONAL TONDO HIGH SCHOOL HIGH SCHOOL 2004 2008 N/A 2008 N/A

N/A

TRADE
COURSE
COLLEGE UNIVERSITY DE MANILA BACHELOR OF SCIENCE IN CRIMINOLOGY 2008 2012 N/A 2012 N/A

GRADUATE STUDIES UNIVERSITY OF THE PHILIPPINES MASTERS IN PUBLIC ADMINISTRATION 2020 2021 12 UNITS N/A N/A

(Continue on separate sheet if necessary) Da

SIGNATURE DATE August 17, 2023

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

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (if applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity
OCTOBER 27,28,29,
RA 6506 BOARD EXAM FOR CRIMINOLOGISTS 80.5% UNIVERSITY OF THE EAST MANILA 0123456 01/30/2025
2012

CAREER SERVICE PROFESSIONAL 80.3% OCTOBER 13, 2013 RAMON MAGSAYSAY HIGH SCHOOL MANILA 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
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)

12/19/2020 PRESENT FIRE OFFICER 3 BUREAU OF FIRE PROTECTION 32,114.00 14 PERMANENT Y

07/01/2018 12/18/2020 FIRE OFFICER 2 BUREAU OF FIRE PROTECTION 30,867.00 12 PERMANENT Y

01/01/2018 06/30/2018 FIRE OFFICER 1 BUREAU OF FIRE PROTECTION 29,668.00 10 PERMANENT Y

01/07/2014 12/31/2016 FIRE OFFICER 1 BUREAU OF FIRE PROTECTION 14,834.00 10 PERMANENT Y

(Continue on separate sheet if necessary)

SIGNATURE DATE August 17, 2023

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

N/A

(Continue on separate sheet if necessary)

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

FIRE OFFICERS BASIC COURSE 05/01/2017 8/27/2017 480 TECHNICAL NATIONAL FIRE TRAINING INSTITUTE

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

DRIVING MEDALYA NG KASANAYAN - 3 N/A

PROGRAMMER (SOFTWARE) MEDALYA NG PAPURI - 5

MEDALYA NG PAGTULONG SA NASALANTA - 2

(Continue on separate sheet if necessary)

SIGNATURE DATE August 17, 2023

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
YES ✘ NO
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, ✘ NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased YES give details:
If YES,
out (abolition) in the public or private sector? ________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except 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 ✘ NO
YES
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
APOLINARIO A AGUILA TONDO, MANILA 09216541325 4.5 cm. X 3.5 cm
(passport size)

MARIA AURORA M MACARAIG SAMPALOC, MANILA 09452154843

Computer generated
or photocopied picture
GREGORIO G GUERERRO QUEZON CITY 09455785314 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 PHOTO
administrative/criminal case/s against 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: BFP ID

ID/License/Passport No.: D12305

Signature (Sign inside the box)
August 17, 2023
Date/Place of Issuance: 01/02/2021 / QUEZON CITY
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before 17th

me thisday of August 2023 , affiant exhibiting his/her validly issued government ID as indicated above.

HEAD OF OFFICE/ REGIONAL ADMIN OFFICER/

NOTARY PUBLIC
Person Administering Oath

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