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
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.

I. PERSONAL INFORMATION
2. SURNAME Loma
NAME EXTENSION (JR., SR)
FIRST NAME Carlo Jovan
MIDDLE NAME

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 05/18/06 Filipino Dual Citizenship
by birth
4. PLACE OF BIRTH Guinobatan, Albay If holder of dual citizenship, Pls. indicate countr
please indicate the details.
5. SEX Male ✓ Female

6 CIVIL STATUS
Single✓ Married 17. RESIDENTIAL ADDRESS P
Widowed Separated House/Block/Lot No. S
Other/s:
Subdivision/Village/Sitio
7. HEIGHT (m) 174 Guinobatan
City/Municipality
8. WEIGHT (kg) 55 ZIP CODE 4503
9. BLOOD TYPE O+ 18. PERMANENT ADDRESS P
House/Block/Lot No. S
10. GSIS ID NO.
Subdivision/Village/Sitio

11. PAG-IBIG ID NO. Guinobatan

City/Municipality

12. PHILHEALTH NO. ZIP CODE 4503

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 20. MOBILE NO. 09076996511

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) carlojovanloma14@gmail.c
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME

NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

25. MOTHER'S MAIDEN NAME

SURNAME Loma
FIRST NAME Carina
MIDDLE NAME Maceda (Continue on separate sheet if necessa

III. EDUCATIONAL BACKGROUND

PERIOD OF HIGHEST LEVEL/
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE
LEVEL ATTENDANCE UNITS EARNED
(Write in full) (Write in full)
(if not graduated)
From To
Guinobatan East Central
ELEMENTARY
School
Marcial O. Rañola Memorial
SECONDARY
School
VOCATIONAL /
TRADE COURSE

COLLEGE

GRADUATE STUDIES
 (Continue on separate sheet if necessary)

SIGNATURE DATE
L DATA SHEET
erience Sheet shall cause the filing of administrative/criminal case/s against the person

BEFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

by naturalization
Pls. indicate country:

Purok-1
Street/Purok
Iraya
Barangay
Alaby
Province
4503
Purok-1
Street/Purok
Iraya
Barangay
Albay
Province

4503

09076996511
carlojovanloma14@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

(Continue on separate sheet if necessary)

YEAR SCHOLARSHIP/ ACADEMIC

GRADUATED HONORS RECEIVED

2018
separate sheet if necessary)

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
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

(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.
28. INCLUSIVE DATES SALARY/JOB/PAY
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY GRADE (if applicable) STATUS OF
(Write in full/Do not abbreviate) (Write in full/Do not abbreviate) SALARY & STEP (Format "00- APPOINTMENT
From To 0")/INCREMENT

(Continue on separate sheet if necessary)

SIGNATURE DATE 06/2/2017
CS FORM 212 (Revis
 LICENSE (if applicable)
Date of
Validity

ate sheet if necessary)

GOV'T SERVICE
(Y/N)

ate sheet if necessary)

06/2/2017
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. NUMBER OF
(Write in full) (mm/dd/yyyy) POSITION /
HOURS
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)

Type of LD
INCLUSIVE DATES OF ATTENDANCE
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS NUMBER OF ( Managerial/ C
(mm/dd/yyyy)
(Write in full) HOURS Supervisory/
Technical/etc)
From To

10

11

12

13

14

15

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMBE
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)
 (Continue on separate sheet if necessary)

SIGNATURE DATE
 / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

rate sheet if necessary)

S ATTENDED
5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

rate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in full)
rate sheet if necessary)

06/2/2017
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 YES NO
any court or tribunal? If YES, give details:
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation, retirement, YES NO
dropped from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) If YES, give details:
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
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten

name tag and signature over
printed name
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and
Computer generated
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the or photocopied picture
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:

ID/License/Passport No.:
Signature (Sign inside the box)

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 o

 If YES, give details (country):

, affiant exhibiting his/her validly issued government ID as indicated above.

CS FORM 212 (Revised 2017), Page 4 of 4