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 HIMPAYAN
NAME EXTENSION (JR., SR)
FIRST NAME ROLITO

MIDDLE NAME GUERRERO

3. DATE OF BIRTH
(mm/dd/yyyy) 9/1/1962 16. CITIZENSHIP ✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH AGUSAN DEL NORTE If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS Mahogany Drive

Widowed Separated House/Block/Lot No. Street
Doña Maria Subd. Tubod
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 1.64 M. ILIGAN CITY LANAO DEL NORTE
City/Municipality Province
8. WEIGHT (kg) 67 Kg. ZIP CODE 9200
18. PERMANENT ADDRESS Mahogany Drive
9. BLOOD TYPE "O"
House/Block/Lot No. Street
10. GSIS ID NO. BP NO.2000169348
Doña Maria Subd. Tubod
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1950-0005-7814 ILIGAN CITY LANAO DEL NORTE

City/Municipality Province

12. PHILHEALTH NO. 19-000719413-0 ZIP CODE 9200

13. SSS NO. 08-0698279-1 19. TELEPHONE NO. 2247029

14. TIN NO. 136936367 20. MOBILE NO. 09355542922

15. AGENCY EMPLOYEE NO. A-1218 21. E-MAIL ADDRESS (if any)

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME HIMPAYAN 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME FLORA Melchizedek Rey Himpayan 02/181994

MIDDLE NAME POSTRERO Gideon Ivan P. Himpayan 9/1/1997

OCCUPATION Housewife Miriam Grace P. Himpayan 10/26/2000

EMPLOYER/BUSINESS NAME n/a

BUSINESS ADDRESS n/a

TELEPHONE NO.

24. FATHER'S SURNAME HIMPAYAN

NAME EXTENSION (JR., SR)
FIRST NAME FRANCISCO

MIDDLE NAME DIAMA

25. MOTHER'S MAIDEN NAME

SURNAME GUERRERO

FIRST NAME FE

MIDDLE NAME CUSTO (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
(Write in full) HONORS
full) (if not graduated) RECEIVED
From To

ELEMENTARY Riverside Central Elementary School Primary 1971 1977 1977

SECONDARY /
VOCATIONAL Agusan National High School SecondaryHigh School 1977 1981 1981

Iligan City Technical Institute General Radio Communication Operator 1984 1986 1986
TRADE
Mindanao University of Science and Bachelor Of Science in Industrial
COURSE
COLLEGE 2008 2009 2009
Technology Technology

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 1 of 6
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
NATIONAL CERTIFICATE II (COMPUTER TESDA REGION 10 (MARIA CRISTINA, ILIGAN 141005020056
11/14/2019
HARDWARE SERVICING) CITY) 62

(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
SERVICE
28. INCLUSIVE DATES SALARY/ JOB/ PAY
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)
NATIONAL POWER CORPORATION
03/28/2019 Present MAINTENANCE FOREMAN 38,085.00 JG13/SG18 PERMANENT Y
(MINGEN-AFD-HRAD)
NATIONAL POWER CORPORATION (AGUS
09/01/2018 03/27/2019 SENIOR ELECTRICIAN 27,442.00 JG11/SG14 PERMANENT Y
4 HEP)
NATIONAL POWER CORPORATION (AGUS
04/01/2018 08/31/2018 SENIOR ELECTRICIAN 26,494.00 PERMANENT Y
4 HEP)
NATIONAL POWER CORPORATION (AGUS
07/01/2015 12/31/2015 SENIOR ELECTRICIAN 10,296.00 PERMANENT Y
4 HEP)
NATIONAL POWER CORPORATION (AGUS
02/01/2015 06/30/2015 SENIOR ELECTRICIAN 10,296.00 PERMANENT Y
4 HEP)
NATIONAL POWER CORPORATION (AGUS
09/01/2014 12/31/2014 SENIOR ELECTRICIAN 12,364.00 PERMANENT Y
4 HEP)
NATIONAL POWER CORPORATION (AGUS
06/01/2014 08/31/2014 SENIOR ELECTRICIAN 12,364.00 PERMANENT Y
4 HEP)
NATIONAL POWER CORPORATION (AGUS
03/03/2014 05/31/2014 SENIOR ELECTRICIAN 12,364.00 PERMANENT Y
4 HEP)
NATIONAL POWER CORPORATION (AGUS
11/05/2013 12/31/2013 SENIOR ELECTRICIAN 12,364.00 PERMANENT Y
4 HEP)
NATIONAL POWER CORPORATION (AGUS
08/05/2013 11/04/2013 SENIOR ELECTRICIAN 12,364.00 PERMANENT Y
4 HEP)
ASAMCO ARABIA ALUMINUM
12/15/2008 05/15/2013 SENIOR ELECTRICIAN 45,000.00 PERMANENT N
MANUFACTURING COMPANY
CITY ENGINEER'S OFFICE (ELECTRICAL
08/15/2004 12/15/2008 SENIOR ELECTRICIAN 6,600.00 PERMANENT Y
SECTION)

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 2 of 6
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
SERVICE
28. INCLUSIVE DATES SALARY/ JOB/ PAY
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)

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 3 of 6
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
EMERGENCY PREPAREDNESS & RESPONSE RE: DISASTER AWARENESS 8 HRS NATIONAL POWER CORPORATION (AGUS
08/11/2016 08/11/2016 TECHNICAL
SEMINAR & EARTHQUAKE DRILL 4&5 HEPC)
16 HRS NATIONAL POWER CORPORATION
QUALITY MANAGEMENT SYSTEM (QMS) 4/7/2015 4/8/2015 MANAGERIAL
(AGUS 4&5 HEPC)
STANDARD FIRST AID BASIC LIFE SUPPORT CARDIO PULMONARY NATIONAL POWER CORPORATION
9/21/2015 9/23/2015 16 HRS TECHNICAL
RESUCITATION TRAINING (AGUS 4&5 HEPC)

4 HRS NATIONAL POWER CORPORATION

SUPPLY INSTALLATION COMMISIONING OF DATA AUTO LOGGING SYSTEM 1/17/2014 1/17/2014 TECHNICAL
(AGUS 4&5 HEPC)
DATA PHIL TECHNOLOGY EDUCATORS
ADVANCED DIGITAL PHOTOGRAPHY 8/5/2011 10/28/2011 52 HRS TECHNICAL
INCORPORATED

52 HRS DATA PHIL TECHNOLOGY EDUCATORS

BASIC DIGITAL PHOTOGRAPHY 7/6/2010 9/24/2010 TECHNICAL
INCORPORATED
DATA PHIL TECHNOLOGY EDUCATORS
BASIC NETWORKING 7/6/2010 9/24/2010 52 HRS TECHNICAL
INCORPORATED

(CA101) COMPUTER AIDED DRAWING COURSE 8/21/2006 8/25/2010 20 HRS TECHNICAL ILIGAN COMPUTER INSTITUTE

(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)

COMPUTER TECHNICIAN PALARONG PAMBANSA 1997 (SWIMMING) COUPLES FOR CHRIST

CAD OPERATOR

GRAPHIC DESIGN

BASKETBALL

BADMINTON

SWIMMING

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 4 of 6
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

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 5 of 6
 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? ________________________________
Due to EPIRA law
________________________________
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
NICHOLAS T. BENIGRA AGUS 4&5 HEPC 3401 3.5 cm. X 4.5 cm
(passport size)

ROLAND I. MIKIN AGUS 4 HEP 3404 With full and handwritten

name tag and signature over
printed name
LORETO R. ALBANO AGUS 4 HEP 3447
Computer generated
42. or photocopied picture
I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and is not acceptable
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: PRC ID CARD

ID/License/Passport No.: 0024727 Signature (Sign inside the box)

Date/Place of Issuance: August 17, 2015 Cag. De Oro City

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 6 of 6