CS Form No.

212

PERSONAL DATA SHEET

Revised 2017

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 VERALLO
JR
FIRST NAME VICENTE
MIDDLE NAME VESABELLA
3. DATE OF BIRTH
(mm/dd/yyyy)
01-18-1982 16. CITIZENSHIP Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH SAGAY CITY,NEGROS OCCIDENTAL If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female

6 CIVIL STATUS Single Married 17. RESIDENTIAL ADDRESS

Widowed Separated House/Block/Lot No.

Other/s:
PUROK MABINULIGON BATO
7. HEIGHT (m) 1,702m
SAGAY CITY NEGROS OCCIDENTAL
8. WEIGHT (kg) 71kg
18. PERMANENT ADDRESS
9. BLOOD TYPE O
PUROK MABINULIGON
10. GSIS ID NO.
Subdivision/Village BATO

11. PAG-IBIG ID NO.

SAGAY CITY NEGROS OCCIDENTAL

12. PHILHEALTH NO. ZIP CODE

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 20. MOBILE NO. 09218103022

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

SR.
FIRST NAME VICENTE
MIDDLE NAME PLAZA
25. MOTHER'S MAIDEN NAME VESABELLA
SURNAME VERALLO
FIRST NAME JOVITA
MIDDLE NAME OLIMBA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

SCHOLARSHIP/
HIGHEST LEVEL/
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE YEAR ACADEMIC
LEVEL UNITS EARNED
(Write in full) (Write in full) (if not graduated)
GRADUATED HONORS
From To RECEIVED
ABOUNDING LIFE CHRISTIAN
ELEMENTARY ACADEMY / BATO ELEMENTARY PRIMARY EDUCATION 1992 1997
SCHOOL
SECONDARY BATO NATIONAL HIGH SCHOOL HIGH SCHOOL 1997 2001

VOCATIONAL / TECHNICAL EDUCATION and

GENERAL ELECTRICITY 2003 2004
TRADE COURSE SKILLS DEVELOPMENT
NORTHERN NEGROS STATE
BACHELOR OF SCIENCE IN
COLLEGE COLLEGE OF SCIENCE & 2006 2010
AGRICULTURAL TECHNOLOGY
TECHNOLOGY
COLEGIO DE STA.RITA DE SAN
GRADUATE STUDIES CARLOS,SAN CARLOS CITY SUPPLEMENTAL DEGREE(BSED) 2015 2016
NEGROS OCCIDENTAL
(Continue on separate sheet if necessary)

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