CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misinterpretation made in the Personal Data Sheet and the Work Experience Sheet shall cause the filing of administrative/criminal case/s aga
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

I. PERSONAL INFORMATION
2. SURNAME CODILLA
NAME EXTENSION (JR., SR
FIRST NAME MA.LOURDES
MIDDLE NAME BASE
3. DATE OF BIRTH
(mm/dd/yyyy) 1/18/1976 16. CITIZENSHIP ✘ Filipino Dual Citizenship
✘ by birth by
4. PLACE OF BIRTH STA.MESA, MANILA If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male ✘ Female

Single ✘ Married 17. RESIDENTIAL ADDRESS PUROK ASLUM

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. S
BRGY 80 M
Other/s:
Subdivision/Village Ba
TACLOBAN CITY LE
7. HEIGHT (m) 1.56
City/Municipality Pr
8. WEIGHT (kg) 55 ZIP CODE

18. PERMANENT ADDRESS PUROK ASLUM

9. BLOOD TYPE A+
House/Block/Lot No. S
BRGY 80 M
10. GSIS ID NO.
Subdivision/Village Ba

11. PAG-IBIG ID NO.

TACLOBAN CITY
City/Municipality Pr

12. PHILHEALTH NO. 1320152722388 ZIP CODE

13. SSS NO. 06-2443434-0 19. TELEPHONE NO.

14. TIN NO. 464-835-376-000 20. MOBILE NO. 09121975143 / 09667542329

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) chasbco@yahoo.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME CODILLA 23. NAME of CHILDREN (Write full name and list all)

FIRST NAME JUANITO JR.

NAME EXTENSION (JR., SR) HANNS BASE CODILLA

MIDDLE NAME SILLAR GIDEON BASE CODILLA

OCCUPATION
KHEN BASE CODILLA

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME BASE

NAME EXTENSION (JR., SR)
FIRST NAME EDGARDO
 MIDDLE NAME ROBLES

25. MOTHER'S MAIDEN NAME

SURNAME CAPILI

FIRST NAME MA.VIRGINIA

MIDDLE NAME NOBLEJAS (Continue on separate sheet if necessary

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY JUSTO LUKBAN ELEMENTARY SSCHOOL PRIMARY 1982 1988

SECONDARY /
VOCATIONAL HOLY INFANT COLLEGE SECONDARY 1988 1992

COLEGIO SAN LORENZO RUIZ/ ASIAN CAREGIVING, DRESSMAKING, FOOD &

DEVELOPMENT FOUNDATION BEVERAGE,COOKERY 2009 2017

TRADE
COURSE
COLLEGE AMA COMPUTER COLLEGE B.S. COMPUTER SCIENCE 1992 1998

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE CS FORM 212 (Re

L DATA SHEET
rience Sheet shall cause the filing of administrative/criminal case/s against the person

EFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Dual Citizenship

by naturalization

Pls. indicate country:

Street
BRGY 80 MARASBARAS
Barangay
LEYTE
Province

Street
BRGY 80 MARASBARAS
Barangay
LEYTE
Province

09121975143 / 09667542329

chasbco@yahoo.com

DATE OF BIRTH (mm/dd/yyyy)

10/9/1994

2/28/1996

4/15/2002
 (Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC HONORS
GRADUATED
RECEIVED

parate sheet if necessary)

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

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
SERVICE
28. INCLUSIVE DATES SALARY/ JOB/ PAY
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)
STATISTICAL RESEACHER, MANUAL PROCESSOR & MACHINE
7/10/2017 4/20/2019 PROCESSOR PHILIPPINE STATISTICS AUTHORITY 409/ DAILY JOB ORDER Y
JGF RECRUITMENT AGENCY/ Maria Orosa St.
Feb. 2015 Dec. 2015 MARKETING STAFF Ermita Manila
500/ DAILY N
ZAREIKO PRODUCTION, INC.EMPLOYMENT
Aug. 2014 Jan. 2015 MARKETING STAFF AGENCY, Roxas Blvd. Pasay City
500/ DAILY N

Nov. 2013 July 2014 MARKETING STAFF YMC Int'l. Recruitment Agency, Paco Manila 500/ DAILY N

Aug. 2013 Oct. 2013 CAREGIVER HOME FOR THE AGED, Singapore 38,000.00 N

2004 2009 Landscape Designer Codilla's Garden, Real St. Tacloban City 30,000.00 N
Aquaria Tropicana, Aquarium Care, Set Up &
2003 2004 Sales Manager Supplies, Paraiso, San Jose, Tacloban City
30,000.00 N
United Laboratories, Inc., Paraiso, San
1999 2003 Database Management 15,000.00 N
Jose, Tacloban City
1998 1999 Data Encoder ACCUDATA, Real St. Tacloban City 8,000.00 N
BASE Internet Shop, Alabang Muntilupa
1994 1998 Data Encoder 6,000.00 N
City
Codilla's Metal Shop, 4th St.,
1992 1994 Sales & Marketing Officer 5,000.00 N
Sampaguita, Tacloban City

(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 / N
From To

Home for the Aged, Catarman Northern Samar Feb. 2010 July 2010 Caregiver

S.O.S. Children's Village, Brgy Tigbao, Tacloban City Aug. 2010 Jan. 2011 Caregiver

(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 Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ( Managerial/ CONDUCTED/ SP
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To

3RD Level Training on April 2019, Labor Force Survey 4/1/2019 4/3/2019 Philippine Stat

3rd Level Training on Labor Force Survey (LFS) & Family Income and Expenditures
1/3/2019 1/9/2019 Philippine Stat
Survey (FIES)

Entrepreneurial Mindsetting & Skills Training 4/13/2018 4/16/2018

Mat and Bag Weaving with Embroidery 2/18/2018 2/23/2018

Food and Beverage Services NC2 1/20/2018 2/1/2018

Dressmaking NC2 Oct. 2017 Dec. 2017

Caregiving NC2

First Aid Traning (Standard)

Philippin

Basic Life Support (Health Care Providers) Philipp

 (Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSH
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

COOKING

LANDSCAPPING

AQUASCAPPING

DRIVING

(Continue on separate sheet if necessary)

SIGNATURE DATE
PLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

Caregiver

Caregiver

heet if necessary)

AMS ATTENDED
years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

Philippine Statistics Authority

Philippine Statistics Authority

Department of Trade & Industry

Palo, Livelihood by Matin Petilla

TESDA Region 8

TESDA Region 8

Colegio de San Lorenzo Ruiz School

Philippine National Red Cross

Philippine National Red Cross

heet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION

(Write in full)

heet if necessary)

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 NO
YES ✘
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, YES ✘ NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased If YES, give details:
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 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
Joanna O. Palana Tolosa, Leyte 09287963061 3.5 cm. X 4.5 cm
(passport size)

Ma. Cristina Mancera Palo, Leyte 09569268757 With full and handwritten
name tag and signature over
printed name
Liduvina Dacuyan Tacloban City 09157482467
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied picture
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 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: PASSPORT

ID/License/Passport No.: P1934927A

Signature (Sign inside the box)

Date/Place of Issuance: FEB.15, 2017/DFA MANILA

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

If YES, give details (country):
, affiant exhibiting his/her validly issued government ID as indicated above.

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