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 MADALA
NAME EXTENSION (JR., SR) N/A
FIRST NAME JUSTINE

MIDDLE NAME CRUZ

3. DATE OF BIRTH
(mm/dd/yyyy) NOVEMBER 26, 1999 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH ALICIA, ISABELA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS 0067 PUROK 3

Widowed House/Block/Lot No. STREET
Separate
d BAGNOS
Other/s:
Subdivision/Village Barangay

7. HEIGHT (m) 1.61 ALICIA ISABELA

City/Municipality Province
8. WEIGHT (kg) 63 ZIP CODE
3306

9. BLOOD TYPE B+ 18. PERMANENT ADDRESS 0067 PUROK 3

House/Block/Lot No. Street

10. GSIS ID NO. N/A BAGNOS

Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A ALICIA ISABELA

City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE

3306

13. SSS NO. 01-3168706-2 19. TELEPHONE NO. N/A

14. TIN NO. 635-988-102 20. MOBILE NO. 09362832184

15. AGENCY EMPLOYEE NO. 00-088-079-00 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
NAME EXTENSION (JR., SR) N/A

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME MADALA

NAME EXTENSION (JR., SR)
FIRST NAME MARCEL SR

MIDDLE NAME RUIZ

25. MOTHER'S MAIDEN NAME

SURNAME CRUZ

FIRST NAME AMELIA

MIDDLE NAME DUTA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY SAN JUAN ELEMENTARY SCHOOL PRIMARY EDUCATION 2006 2012 GRADUATED 2012 N/A

SECONDARY ALICIA HIGH SCHOOL HIGH SCHOOL 2012 2018 GRADUATED 2018 N/A
VOCATIONAL /

N/A
TRADE
COURSE ISABELA STATE UNIVERSITY- BACHELOR OF SCIENCE IN
COLLEGE 2018 2022 GRADUATED 2022 N/A
ANGANDANAN CAMPUS CRIMINOLOGY

GRADUATE STUDIES N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL RATING DATE OF
LAWS/ CES/ CSEE BARANGAY (If Applicable) EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
ELIGIBILITY / DRIVER'S LICENSE CONFERMENT NUMBER Date of
Validity

RA 6506 79.60% 04/3-5/2023 CAUAYAN CITY ISABELA 0250846 11/26/2026

NAPOLCOM ENTRANCE EXAM 77.23% 12/3/2022 TUGUEGARAO CITY 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.
28. SALARY/ JOB/ GOV'T SERVICE
INCLUSIVE DATES (mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY PAY GRADE (if
MONTHLY applicable)& STATUS OF
(Write in full/Do not SALARY STEP (Format APPOINTMENT
abbreviate) (Write in full/Do not abbreviate) "00-0")/
INCREMENT (Y/ N)
From To

N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE
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
(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 HOURS
( Managerial/ CONDUCTED/ SPONSORED BY
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

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)

DRIVING N/A N/A

PLAYING FOOTBALL

(Continue on separate sheet if necessary)

SIGNATURE DATE
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:
3 YES ✘ NO
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
JOCEL LANGEO PUROK3, BAGNOS, ALICIA, ISABELA 9069614829 3.5 cm. X 4.5 cm
(passport size)

MARC LUYEN PUROK3, BAGNOS, ALICIA, ISABELA 9157105248 With full and handwritten
name tag and signature over
printed name
ROBERT LIMOSIN PUROK3, BAGNOS, ALICIA, ISABELA 9557089261 Computer generated
or photocopied picture
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and is not acceptable
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

ID/License/Passport No.: 0250846

Signature (Sign inside the box)

Date/Place of Issuance: 07/03/2023, SANTIAGO 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