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 filling 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
SOBRINO
NAME EXTENSION(JR., SR.)
FIRST NAME
MELCA
MIDDLE NAME
LOPEZ
3. DATE OF BIRTH
(mm/dd/yyyy) 16. CITIZENSHIP Filipino Dual Citizenship
06/01/1973 by birth by naturalization
4. PLACE OF BIRTH If holder of dual citizenship, Pls. indicate country:
San Fernando,Romblon
please indicate the details.
5. SEX Male Female

Single Married 17. RESIDENTIAL ADDRESS 12 Francisco

6. CIVIL STATUS House/Block/Lot No. Street
Widowed Separated

Other/s:
Bagong Ilog
Subdivision/Village Barangay

7. HEIGHT(m) CITY OF PASIG, NCR - PASIG

1.5 City/Municipality Province
8. WEIGHT(kg) ZIP CODE
54 1600
9. BLOOD TYPE 18. PERMANENT ADDRESS 12 Francisco
O+ House/Block/Lot No. Street
10. GSID ID NO. Bagong Ilog,
2005751019 Subdivision/Village Barangay

11. PAG-IBIG ID NO. CITY OF PASIG, NCR - PASIG

121070329206 City/Municipality Province

12. PHILHEALTH NO. ZIP CODE

010514823699 1600
13. SSS NO. 19. TELEPHONE NO.
N/A 09062071202
14. TIN NO. 20. MOBILE NO.
414354092 09062071202
15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any)
4416219 Iyahlopez25@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN(Write full name ad list all) DATE OF BIRTH(mm/dd/yyyy)
Sobrino
NAME EXTENSION(JR., SR.)
FIRST NAME Herbert Honey Lett Lopez Sobrino 10/22/1994
MIDDLE NAME Chistine Bertte Lopez Sobrino 06/02/1997
Cabinbin
OCCUPATION Self Employed Christian Bert Lopez Sobrino 12/17/1998

EMPLOYER/BUSINESS NAME Steven Nazarette Lopez Sobrino 09/07/2001

BUSINESS ADDRESS 12 Francisco Street Bagong Ilog Pasig City

TELEPHONE NO. 09268551001
24. FATHER'S SURNAME
Lopez
FIRST NAME NAME EXTENSION(JR., SR.)
Ricardo Sr.
MIDDLE NAME
Deang
25. MOTHER'S MAIDEN NAME Melita Marin Iya
SURNAME
Iya
FIRST NAME
Melita
MIDDLE NAME
Marin
III. EDUCATIONAL BACKGROUND
26. PERIOD OF ATTENDANCE HIGHEST LEVEL/ SCHOLARSHIP/
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE UNITS EARNED YEAR ACADEMIC
LEVEL HONORS
(Write in full) (Write in full) (if not graduated) GRADUATED
RECEIVED
From To

Espana Elementary School Primary 1980 1986 Graduated 1986 Salutatorian

ELEMENTARY

SECONDARY Espana National High School Secondary 1986 1990 GRADUATED 1990 Second
Honorable
Mention
VOCATIONAL /
TRADE COURSE N/A N/A N/A N/A N/A N/A N/A

COLLEGE Philippine Normal University Tertiary A/B Psychology 1991 1993 2nd Year Undergraduate

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

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE

Pasig City GEMS 2022-05-11 15:44:51 CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
LICENSE(If applicable)
27. CAREER SERVICE/RA 1080(BOARD/BAR) UNDER SPECIAL
RATING DATE OF EXAMINATION PLACE OF EXAMINATION / CONFERMENT
LAWS CES/CSEE BARANGAY CONFERMENT
ELIGIBILITY/DRIVER'S LICENSE if Applicable NUMBER Date of
Validity

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

City Government of Pasig - SANGGUNIANG

01/01/2022 PRESENT Administrative Aide III(Utility Worker II) 14,125.00 3-1 Casual Yes
PANLUNGSOD - CITY COUNCIL

Sanggunian Panlungsod/Office of Coun. Ferdinand A.

02/03/2020 PRESENT ADMINISTRATIVE AIDE III (UTILITY WORKER II) 13,572.00 3 CASUAL Yes
Avis

09/07/2011 07/25/2014 Liaison officer Terms Concrete Testing 12,000.00 N/A Regular No

(Continue on separate sheet if necessary) **DISCLAIMER ongoing migration

SIGNATURE DATE

Pasig City GEMS 2022-05-11 15:44:51 CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
29. NAME & ADDRESS OF ORGANIZATION (Write in full) INCLUSIVE DATES
(mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK

From To

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

(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 (mm/dd/yyyy) NUMBER OF HOURS (Managerial/ CONDUCTED/ SPONSORED BY
Supervisory/
(Write in full) Technical/etc)
(Write in full)

From To
N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

VII. OTHER INFORMATION

31. SPECIAL SKILLS and HOBBIES 32. NON-ACADEMIC DISTINCTIONS / RECOGNITION 33. MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in full) (Write in full)

Typing Book Keeping Filing

(Continue on separate sheet if necessary)

SIGNATURE DATE
Pasig City GEMS2022-05-11 15:44:51 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 appointed,

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 any court or tribunal? YES NO
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 out (abolition) in the public or private sector? If YES, give details: ____________________________
Resigned

38. a. Have you ever been candidate in a national or local election held within the last year
(except Barangay election)? YES NO
If YES, give details:

b. Have you resigned from the government service during the three (3)-month period before YES NO
the last 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
Jose Nilo C.Abrenio Bagong Ilog,Pasig City 8671-0681 the last 6 months
3.5 cm. X 4.5 cm
(passport size)
Myla Rose R. Castilla 12 San Roque St.,Bagong Ilog,Pasig City 09184717211
With full and handwritten
name tag and signature over
printed name
Mae Lanie Gomez Caniogan,Pasig City 8671-0774
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied picture
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. I is not acceptable
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 filling of administrative/criminal case/s
against me. PHOTO

Government Issued ID (i.e. Passport, GSIS, SSS, PRC, Driver's License, etc.)
PLEASE INDICATE ID Number and Date of Issuance
Government Issued ID: Tin Id

ID/License/Passport No.: 414354092000

Signature (Sign inside the box)

Date/Place of Issuance: 10/26/2011 / Pasig 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

Pasig City GEMS 2022-05-11 15:44:51 CS FORM 212 (Revised 2017), Page 4 of 4
 WORK EXPERIENCE SHEET

Instructions: 1. Include only the work experiences relevant to the position being applied for.
2. The duration should include start and finish dates, if known,month in abbreviated form,
if known, and year in full. For the current position, use the word Present, e.g., 1998-
Present. Work experience should be listed starting with the most recent/present
employment.

____________________________
(Signature Over Printed Name
of Employee/Applicant)
Date:_____________________

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