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 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 GALINATO
NAME EXTENSION (JR., SR)
FIRST NAME JEREMY
MIDDLE NAME BARADILLO
3. DATE OF BIRTH
(mm/dd/yyyy) MARCH 5, 1997 ✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH SURIGAO CITY If holder of dual citizenship, Pls. indicate country:
5. SEX please indicate the details.
✘ Male Female
17. RESIDENTIAL ADDRESS
6 CIVIL STATUS ✘ Single ✘ Married
Widowed Separated
Other/s:

7. HEIGHT (m) 1.72

8. WEIGHT (kg) 75 ZIP CODE
18. PERMANENT ADDRESS P-4
9. BLOOD TYPE "O"
House/Block/Lot No. Street
LADGARON
10. GSIS ID NO.
Subdivision/Village Barangay
CLAVER SDN
11. PAG-IBIG ID NO.
City/Municipality Province
12. PHILHEALTH NO. ZIP CODE 8410

13. SSS NO. 35-0311477-5 19. TELEPHONE NO. N/A

14. TIN NO. 471-228-499 20. MOBILE NO. 09207835417

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) jeremygalinato123@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 GALINATO

NAME EXTENSION (JR., SR)
FIRST NAME BENJAMIN

MIDDLE NAME TEJARES

25. MOTHER'S MAIDEN NAME CHERRYLYN NODALO BARADILLO

SURNAME GALINATO

FIRST NAME CHERRYLYN

MIDDLE NAME BARADILLO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY LADGARON ELEMENTARY SCHOOL 2004 2009 2009

SECONDARY /
VOCATIONAL SURIGAO EDUCATION CENTER 2009 2013 2013

APOSTOLIC INSTITURE OF MISITRIES 2013 2015 2015

TRADE
COURSE
COLLEGE SAINT PAUL UNIVERSITY SURIGAO AB POLITICAL SCIENCE 2015 2019 2019

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE MARCH 15, 2021 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
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)

5/12/2020 2/24/21 PARALEGAL RAMA BAENA TAN & ANG LAW OFFICES

(Continue on separate sheet if necessary)

SIGNATURE DATE MARCH 15, 2021 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
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

N/A

(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
(Write in full)
in full)

DRIVING

COMPUTER LITERATE

ue on separate sheet if necessary)

SIGNATURE
DATE MARCH 15, 2021 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
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? ________________________________
RESIGNATION
________________________________
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
ATTY. ALVIN PRANDY T. CANTA SURIGAO CITY the last 6 months
3.5 cm. X 4.5 cm
HAZEL B. MONTALBA, PhD SURIGAO CITY (passport size)

LADNLEY T. CHUA, MD CLAVER With full and handwritten

name tag and signature over
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete printed name
statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. I Computer generated
authorize the agency head / authorized representative to verify/validate the contents stated herein. I agree that any or photocopied picture
misrepresentation made in this document and its attachments shall cause the filing of administrative/criminal case/s is not acceptable
PHOTO
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: DRIVERS LICENSED
ID/License/Passport No.: KO7-15-001335
Signature (Sign inside the box)
Date/Place of Issuance: SURIGAO CITY MARCH 1, 2021
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