CS Form No.

212

PERSONAL DATA SHEET

Revised 2017

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 PALOMA
NAME EXTENSION (JR., SR)
FIRST NAME MARY ROSE

MIDDLE NAME QUIGOD

3. DATE OF BIRTH
(mm/dd/yyyy)
01/12/1987 16. CITIZENSHIP Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH SAN ROQUE, SURIGAO DEL SUR If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female

Single Married 17. RESIDENTIAL ADDRESS PUROK 32 CORTES SITIO BACUD

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
LUNA
Other/s:
Subdivision/Village Barangay
SURIGAO CITY SURIGAO DEL NORTE
7. HEIGHT (m) 4'9
City/Municipality Province
8. WEIGHT (kg) 54 ZIP CODE 8400

18. PERMANENT ADDRESS PUROK 32 CORTES SITIO BACUD

9. BLOOD TYPE A+
House/Block/Lot No. Street
LUNA
10. GSIS ID NO.
Subdivision/Village Barangay

11. PAG-IBIG ID NO. SURIGAO CITY SURIGAO DEL NORTE

City/Municipality Province

12. PHILHEALTH NO. ZIP CODE 8400

13. SSS NO. 0819402190 19. TELEPHONE NO.

14. TIN NO. 20. MOBILE NO. 09501542862

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

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME PALOMA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) CHRIS DAVE PALOMA
FIRST NAME CELESTINO 12/31/2009

MIDDLE NAME LAMBAN CLOUIE MAE PALOMA 10/17/2011

OCCUPATION SERVICE DRIVER (PRIVATE)

EMPLOYER/BUSINESS NAME ROBEL BORJA

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME

NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

25. MOTHER'S MAIDEN NAME

SURNAME

FIRST NAME

MIDDLE NAME (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY VERDU ELEMENTARY SCHOOL 2001

BAYUGAN NATIONAL COMPREHENSIVE HIGH

SECONDARY
SCHOOL 2004

VOCATIONAL /
TRADE COURSE
TESDA (CAREGIVING) 2018

COLLEGE

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 1 of 4