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 N/A (If Not Applicable)

MIDDLE NAME SANTOS

3. DATE OF BIRTH
12/25/1991 16. CITIZENSHIP
(mm/dd/yyyy)
ALL DETAILS MUST BE
Do not interchange and follow the format
Filipino Dual Citizenship
by birth
by
4. PLACE OF BIRTH
IN CAPITAL LETTERS If holder of dual citizenship,

please indicate the details.

Pls. indicate country:naturalization

5. SEX Male Female

17. RESIDENTIAL ADDRESS Block 15, Lot 5 Carmel Street
6 CIVIL STATUS Single Married House/Block/Lot No. Just Tick the box, if
Street
Widowed Separate Just Tick the box, doHeight Village
Sosana you are a dual citizen
Barangay Pinagkaisahan
Other/s:
Just Tick the box, do
d not remove the Subdivision/Village
box Barangay
not remove the box Cubao, Quezon City Metro Manila (Fixed Metro Manila if within NCR)
7. HEIGHT (m)
City/Municipality Province
8. WEIGHT (kg) ZIP CODE 1105

9. BLOOD TYPE
- 18. PERMANENT ADDRESS
House/Block/Lot No.
Carmel Street
Street

10. GSIS ID NO.

- Subdivision/Village
Pulo
Barangay

11. PAG-IBIG ID NO.

- Cab
City/Municipality Province

12. PHILHEALTH NO.

- ZIP CODE 1105

13. SSS NO.

- 19. TELEPHONE NO.
NOT NCR

14. TIN NO.

- 20. MOBILE NO.

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any)

II. FAMILY BACKGROUND Write N/A

22. SPOUSE'S SURNAME if not 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

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

MIDDLE NAME
Do not
OCCUPATION
write None
EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME

NAME EXTENSION (JR., SR)
FIRST NAME
N/A if None
MIDDLE NAME

25. MOTHER'S MAIDEN NAME LEAVE THIS BLANK

SURNAME N/A if None

One N/A per Item
FIRST NAME
only. Leave this blank
MIDDLE NAME N/A if None. (Continue on separate sheet if necessary) if you do not
One N/A per Item have any
III. EDUCATIONAL BACKGROUND only. children.

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

ELEMENTARY
N/A (Single) PRIMARY EDUCATION

SECONDARY /
VOCATIONAL HIGH SCHOOL

Put only 1 N/A on this row if None. COMPLETE COURSE TITLE

TRADE
COURSE COMPLETE COURSE TITLE (EX. BACHELOR OF
COLLEGE Complete name of School. Do not abbreviate. SCIENCE IN NURSING)
Do not write on this portion
GRADUATE STUDIES Put only 1 N/A on this row if None. COMPLETE COURSE TITLE INDICATE # OF UNITS IF
UNDER GRAD.

(Continue on separate sheet if necessary)

DATE OF PUBLICATION
SIGNATURE DATE EX. OCTOBER 25, 2021
BFP-QSF-HRMD-018 Rev. ØØ (04.18.18) 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
Fill up if Eligible Passer

(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)

DOUBLE CHECK COMPLETE COMPLETE NAME OF

THE DATES. DO POSITION
OFFICE/DEPARTMENT. BASIC
NOT TITLE. DO NOT SALARY SG-10
INTERCHANGE. ABBREVIATE. DO NOT ABBREVIATE.
FOLLOW
FORMAT
MM/DD/YYYY START FROM
RECENT DATE
10/01/2015 PRESENT FIRE OFFICER 1 BUREAU OF FIRE PROTECTION 29,668 SG-10 PERMANENT Y

6/25/2014 9/30/2015 FIRE OFFICER 2 BUREAU OF FIRE PROTECTION 29,668 SG-10 TEMPORARY Y

08/30/2013 06/24/2014 FIRE OFFICER 1 BUREAU OF FIRE PROTECTION 29,668 SG-10 PERMANENT Y

AND SO ON
AND SO FORT. This must
coincide with the SOS
(Statement of Service)

(Continue on separate sheet if necessary)

SIGNATURE DATE
OCTOBER 25, 2021
BFP-QSF-HRMD-001 Rev. ØØ (04.18.18) 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 IF NONE. ONE N/A IS ENOUGH DOUBLE CHECK INCLUDE

DATE FORMAT. # OF
DO NOT HOURS
INTERCHANGE

(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) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To

WRITE THE COMPLETE START FROM INCLUDE INCLUDE WRITE THE COMPLETE
TITLE OF RECENT. # OF TYPLE OF NAME OF OFFICE OR
DOUBLE CHECK HOURS LEARNING
TRAINING/PROGRAM. DATE FORMAT. DEV'T SPONSOR.
DO NOT
INTERCHANGE

(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)

PUT N/A IF NONE. ONE N/A IS ENOUGH PUT N/A IF NONE. ONE N/A IS ENOUGH PUT N/A IF NONE. ONE N/A IS ENOUGH

(Continue on separate sheet if necessary)

SIGNATURE DATE OCTOBER 25, 2021

BFP-QSF-HRMD-001 Rev. ØØ (04.18.18) 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
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,
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
FOR ITEMS 34 to 40 If YES, please specify:
b. Are you a person with disability? * DO NOT LEAVE ANY ITEM YES NO
UNANSWERED. If YES, please specify ID No:
c. Are you a solo parent? * DO NOT REMOVE THE BOX. YES NO
If YES, please specify ID No:

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAME
*CLEAR
ADDRESS
PASSPORT SIZE PICTURE
TEL. NO.
W/O HEADGEAR ID picture taken within
the last 6 months
*NAMETAG- SIGNATURE OVER 3.5 cm. X 4.5 cm
(passport size)
PRINTED NAME(PREVIOUS
RANK) With full and handwritten
name tag and signature over

42.
*NAME MUST BE
I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and
printed name

complete statement pursuant to the provisions of pertinent laws, rulesHANDWRITTEN

and regulations of theNOT PRINTED
Republic of the Computer generated
or photocopied picture
Philippines. I authorize the agency head/authorized representative to verify/validate the contents stated herein. is not acceptable
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:

ID/License/Passport No.:
Signature (Sign inside the box)
OCTOBER 25, 2021
Date/Place of Issuance:
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this OCTOBER 25, 2021 , affiant exhibiting his/her validly issued government ID as indicated above.

CITY FIRE DIRECTOR/DISTRICT FIRE DIRECTOR

Person Administering Oath

BFP-QSF-HRMD-001 Rev. ØØ (04.18.18) CS FORM 212 (Revised 2017), Page 4 of 4