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 LEE
NAME EXTENSION (JR.)
FIRST NAME JALOU

MIDDLE NAME BACAYANA

3. DATE OF BIRTH
(mm/dd/yyyy) 09/21/1990 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH IGPIT, OPOL, MIS. OR. If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS COL. AMANDO DUMLAO ST.
Widowed Separated House/Block/Lot No. Street
TANKULAN
Other/s:
Subdivision/Village Barangay
MANOLO FORTICH BUKIDNON
7. HEIGHT (m) 5'2
City/Municipality Province
8. WEIGHT (kg) 60 ZIP CODE 8703

18. PERMANENT ADDRESS COL. AMANDO DUMLAO ST.

9. BLOOD TYPE A+
House/Block/Lot No. Street
TANKULAN
10. GSIS ID NO. N/A
Subdivision/Village Barangay
MANOLO FORTICH BUKIDNON
11. PAG-IBIG ID NO. 912244240735
City/Municipality Province

12. PHILHEALTH NO. 15-050303594-6 ZIP CODE 8703

13. SSS NO. 08-1896429-9 19. TELEPHONE NO.

14. TIN NO. N/A 20. MOBILE NO. 09559546049

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) jalou.lee@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 LEE

NAME EXTENSION SR.)
FIRST NAME JONATHAN

MIDDLE NAME GABITANO

25. MOTHER'S MAIDEN NAME

SURNAME BACAYANA

FIRST NAME ALICE

MIDDLE NAME OBSIOMA (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

ELEMENTARY MANOLO FORTICH CENTRAL ELEMENTARY SCHOOL PRIMARY EDUCATION 1997 2003 2003 N/A

VOCATIONAL /
SECONDARY MANOLO FORTICH NATIONAL HIGH SCHOOL SECONDARY EDUCATION 2003 2007 2007 N/A

N/A N/A N/A N/A N/A N/A

TRADE BACHELOR IN PUBLIC ADMINISTRATION MAJOR
COLLEGE
COURSE BUKIDNON STATE UNIVERSITY
IN LOCAL GOV.
2009 2014 2014 N/A

TVL COURSES

(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

N/A N/A 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.
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)

3/12/2014 PRESENT ADMIN. AIDE (CLERK) LGU MANOLO FORTICH 8500.00 JOB ORDER YES

1/6/2014 11/21/2014 CLERK/G.I.P LGU-DOLE 4500.00 JOB ORDER YES

OPEN
1/10/2011 1/10/2012 CASHIER JOLLIBEE FOODS CORP. 6000.00 NO
CONTRACT

(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

SERVICE QUALITY FOR KEY GENERATORS 07/18/2017 07/18/2017 8HRS MANAGERIAL REGIONAL WAGES & PROD.

16TH NATIONAL PESO CONGRESS 10/13/2016 10/15/2016 74HRS TECHNICAL DEPARTMENT OF LABOR & EMPLOYMENT

CAPACITY BUILDING ACTIVITY FOR OWWA MIGRANTS DESK OFFICES/PARTNERS INS. 12/10/2015 11/13/2015 16HRS TECHNICAL OWWA

2017 SPES & BICEEP IMPLEMENTATION ORIENT. 01/31/2017 01/31/17 8HRS TECHNICAL DOLE

(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)

COMPUTER LITERATE N/A N/A

(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.

ROGER O. MOLINA DICKLUM, MANOLO FORTICH BUKIDNON 017-729-3538

ROY T. ANDAM MALUKO, MANOLO FORTICH, BUKIDNON 9052173831

LORNA A. ANGCO VILLA TRINITAS, BUGO, CDEO CITY 9365800525

42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and
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: VOTERS ID

ID/License/Passport No.: VIN-1314-00143--12190JBL200000

Signature (Sign inside the box)
MARCH 19,2018
Date/Place of Issuance:
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