CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misrepresentation made in the Personal Data Sheet and the Work Experience Sheet shall cause the filing of administrative/criminal case/s aga
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. (D

I. PERSONAL INFORMATION
2. SURNAME DELIZO
III
FIRST NAME EUFEMIANO ALBERT

MIDDLE NAME SETERRA

3. DATE OF BIRTH
(mm/dd/yyyy) 7/1/1992 16. CITIZENSHIP FILIPINO

4. PLACE OF BIRTH SAN JOAQUIN, ILOILO CITY If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX MALE

17. RESIDENTIAL ADDRESS PU

6 CIVIL STATUS SINGLE
House/Block/Lot No. S
FRANCIA WEST
Subdivision/Village Ba
LA
7. HEIGHT (m) 1.59M
City/Municipality P
8. WEIGHT (kg) 55 ZIP CODE 2509

18. PERMANENT ADDRESS PU

9. BLOOD TYPE "B"
House/Block/Lot No. S
FRANCIA WEST
10. GSIS ID NO. N/A
Subdivision/Village Ba
LA
11. PAG-IBIG ID NO. N/A
City/Municipality P

12. PHILHEALTH NO. N/A ZIP CODE 2509

13. SSS NO. 01-2647264-8 19. TELEPHONE NO. N/A

14. TIN NO. N/A 20. MOBILE NO. 0995-0717-459

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) N/A
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME DELIZO

NAME EXTENSION (JR., SR) JR
FIRST NAME EUFEMIANO ALBERT
 MIDDLE NAME GALBAN

25. MOTHER'S MAIDEN NAME SIENA

SURNAME DELIZO

FIRST NAME FRANCISCA

MIDDLE NAME SETERRA (Continue on separate sheet if necessary

III. EDUCATIONAL BACKGROUND

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

YEAR YEAR
ELEMENTARY MATAMBOG ELEMENTARY SCHOOL
2000 2006

SECONDARY /
VOCATIONAL TUBAO NATIONAL HIGH SCHOOL YEAR 2006 YEAR 2010

N/A

TRADE
COURSE YEAR
COLLEGE POLYTECHNIC COLLEGE OF LA UNION BACHELOR OF SCIENCE IN CRIMINOLOGY YEAR 2011
2015

GRADUATE STUDIES N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE Janua

 DATA SHEET
rience Sheet shall cause the filing of administrative/criminal case/s against the person

EFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

III

FILIPINO

Pls. indicate country:

PUROK#7
Street
FRANCIA WEST, TUBAO, LA UNION
Barangay
LA UNION
Province
2509

PUROK#7
Street
FRANCIA WEST, TUBAO, LA UNION
Barangay
LA UNION
Province

N/A

0995-0717-459

[email protected]

DATE OF BIRTH (mm/dd/yyyy)

N/A

FEBUARY 6, 1962
 DECEMBER 17,1960

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2006

2010

2015

arate sheet if necessary)

January 21, 2019

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (if ap
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

BAGUIO CITY/ KING'S COLLEGE LA

BOARD EXAM 81.1 OCT. 2015 0120935
TRINIDAD BENGUET

(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
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

Jan. 2018 Dec. 2018 Review Assistant Prudence Research and Review Center 9740.00 Casual

Jul. 2017 Dec. 2017 Review Assistant Prudence Research and Review Center 8, 000 Casual

Jan. 2017 Jun. 2017 Security Personnel SYMEX SCRTY AGENCT, INC. 8, 000 Casual

Jan. 2016 Dec. 2016 Review Assistant Prudence Research and Review Center 8, 000 Casual
 (Continue on separate sheet if necessary)

SIGNATURE DATE January 21, 2019

CS FORM 212 (Revised 20

 LICENSE (if applicable)

Date of
Validity

7/1/2022

arate sheet if necessary)

GOV'T
SERVICE

(Y/ N)

N
arate sheet if necessary)

January 21, 2019

CS FORM 212 (Revised 2017), Page 2 of 4

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 /
From To

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

N/A
 (Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERS
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

PROFICIENT IN BOTH MICROSOFT EXCEL PROFE

AND WORD ASSOCI
COOKING

READING NEWS PAPER

WATCHING NEWS

(Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

eparate sheet if necessary)

ROGRAMS ATTENDED
five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)
eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)
PROFESSIONAL CRIMINOLOGIST
ASSOCIATION OF THE PHILIPPINES

eparate sheet if necessary)

January 21, 2019

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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
________________________________
NO

35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
NO
________________________________
b. Have you been criminally charged before any court?
If YES, give details:
________________________________
Date Filed: NO
________________________________
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?
If YES, give details:
________________________________
NO
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation,
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? ________________________________
NO
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)?
If YES, give details: NO

b. Have you resigned from the government service during the three (3)-month period before the last
election to promote/actively campaign for a national or local candidate? If YES, give details: NO
39. Have you acquired the status of an immigrant or permanent resident of another country?
If YES, give details (country):
NO
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?
If YES, please specify: NO
b. Are you a person with disability?
If YES, please specify ID No: NO
c. Are you a solo parent?
If YES, please specify ID No: NO

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

ID picture taken within

NAME ADDRESS TEL. NO.
the last 6 months
3.5 cm. X 4.5 cm
JANNETH NIDOY FRANCIA WEST, TUBAO, LA UNION 9663692842 (passport size)

With full and handwritten

SHIRLEY P. AYEO-EO QUEZON HILL, BAGUIO CITY 9098080976 name tag and signature over
printed name

Computer generated
JUNAS A. DIFUNTORUM ARINGAY, LA UNION 9053233662 or photocopied picture
is not acceptable
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and
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/License/Passport No.: 0120935

Signature (Sign inside the box)
January 21, 2019
Date/Place of Issuance: 1/03/2019, PRC BAGUIO
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