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 CAPULONG
NAME EXTENSION (JR., SR)
FIRST NAME KEN CEDRIC

MIDDLE NAME GALICHA

3. DATE OF BIRTH
5/26/1986 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH MANILA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS #60 DON PEDRO

Widowed House/Block/Lot No. Street

Separate
DON PEDRO MARULAS
Other/s: d
Subdivision/Village Barangay
VALENZUELA PAMPANGA
7. HEIGHT (m) 1.626
City/Municipality Province
8. WEIGHT (kg) 75 ZIP CODE 4503

18. PERMANENT ADDRESS #60 DON PEDRO

9. BLOOD TYPE O+
House/Block/Lot No. Street

10. GSIS ID NO. DON PEDRO MARULAS

Subdivision/Village Barangay
11. PAG-IBIG ID NO.
VALENZUELA PAMPANGA

12. PHILHEALTH NO. ZIP CODE City/Municipality Province

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 488-737-784 20. MOBILE NO. 0917-127-7311

15. AGENCY EMPLOYEE NO. 534861 21. E-MAIL ADDRESS (if any) kencedriccapulong@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME CAPULONG

NAME EXTENSION (JR., SR)
FIRST NAME VIC

MIDDLE NAME SUAREZ

25. MOTHER'S MAIDEN NAME QUIMBA

SURNAME CAPULONG

FIRST NAME EDEN

MIDDLE NAME GALICHA (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
HONORS
(Write in full)
full) (if not graduated) RECEIVED
From To

BEST IN
ELEMENTARY NOTRE DAME OF GREATER MANILA 2003 2006 2006 MATH
WITH
SECONDARY /
VOCATIONAL NEW ERA UNIVERSITY 2006 2010 2010
HONORS

TRADE
COURSE
 BACHELOR OF SCIENCE IN MECHANICAL
COLLEGE NEW ERA UNIVERSITY
ENGINEERING
2011 2016 2016

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE
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
MECHANICAL ENGINEER LICENSURE
75.60% MARCH 30-31,2016 UNIVERSITY OF THE EAST 0091205 12/20/2019
EXAMINATION

(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
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To
(Y/ N)

8/1/2016 7/27/2018 Senior Engineer National Housing Authority, NGCHDP SG-16 EH

NHA - MPMO
8/2/2018 PRESENT Senior Engineer SG-16 EH
( Marawi Project Management Office )

(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

(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/ SPONSORED BY
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

Electrical and Mechanical Troubleshooting 6/21/2014 8/25/2014 100.0 Technical Sofitel Philippine Plaza

HVAC Design and Troubleshooting 6/21/2014 8/25/2014 250.0 Technical Sofitel Philippine Plaza

250.0
HVAC Operating and Maintenance 6/21/2014 8/25/2014 Technical Sofitel Philippine Plaza

9/10/2013 9/11/2013 8.0 Philippine Society of Mechanical Engineer

Automotive Service Seminar Technical

8/27/2013 8/28/2013 16.0 New Era University

HVAC Seminar Technical

10/9/2013 10/10/2013 8.0 New Era University

Induction Motor Essentials Technical

1/10/2017 1/10/2017 8.0 Engineering I.N.C

Sustainable Practice in Plumbing Technical

1/11/2017 1/11/2017 8.0 Engineering I.N.C

Firepro-Hydraulic Calculations Technical

1/12/2017 1/12/2017 8.0 Engineering I.N.C

MEPF Technopreneurship Technical

1/13/2017 1/13/2017 8.0 Engineering I.N.C

Basic MEPF Design for a Mix-Use Building Technical

1/14/2017 1/14/2017 8.0 Engineering I.N.C

Common Error in Sanitary Systems Technical

(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)

Automotive Servicing United Architects of the Philippines - UAP

Electro-Mech Troubleshooting

AUTOCAD
Ms Word, Excel, Powepoint

Adobe Photoshop

Basketball

Badminton
(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
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, 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
RODERICK T. IBAÑEZ QUEZON CITY 0998-968-7932 3.5 cm. X 4.5 cm
(passport size)

Engr. Hector Lee, PME QUEZON CITY With full and handwritten
name tag and signature over
printed name
Arch. Gabriel Rafael Nabong PAMPANGA CITY 0920-915-7716
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: PRC

ID/License/Passport No.: 0091205

Signature (Sign inside the box)

Date/Place of Issuance: MANILA/04-15-2016

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