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 AMOLAT
NAME EXTENSION (JR., SR)
FIRST NAME JECTOFFER
MIDDLE NAME LUBON
3. DATE OF BIRTH
(mm/dd/yyyy) 10/26/85 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH MANINGALAO, LAS NIEVES 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 N/A P-1
Widowed Separated House/Block/Lot No. Street
P-6 MANINGALAO
Other/s:
Subdivision/Village Barangay
LAS NIEVES AGUSAN DEL NORTE
7. HEIGHT (m) 1.58
City/Municipality Province
8. WEIGHT (kg) 55 ZIP CODE 8610
18. PERMANENT ADDRESS N/A P-1
9. BLOOD TYPE O
House/Block/Lot No. Street
P-6 MANINGALAO
10. GSIS ID NO. CRN-0111-1018030
Subdivision/Village Barangay
Las Nieves Agusan del Norte
11. PAG-IBIG ID NO. On process
City/Municipality Province
12. PHILHEALTH NO. 18-025142660-9 ZIP CODE 8610
13. SSS NO. NONE 19. TELEPHONE NO. NONE
14. TIN NO. 945-112-486 20. MOBILE NO. 09219409339
15. AGENCY EMPLOYEE NO. On process 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) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME N/A Izza Belle D. Amolat 4/1/2010
MIDDLE NAME N/A
OCCUPATION N/A
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME AMOLAT
FIRST NAME ALAN
MIDDLE NAME BETE
25. MOTHER'S MAIDEN NAME
SURNAME LUBON
FIRST NAME NOEMI
MIDDLE NAME CATIGARA (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
HONORS
(Write in full)
full) (if not graduated) RECEIVED
From To
ELEMENTARY COMEMBO ELEMENTARY SCHOOL ELEMENTARY EDUCATION 3/6/2003 03/27/2009 GRADUATED 1998 NONE
SECONDARY
VOCATIONAL / TUNGAO NATIONAL HIGH SCHOOL SECONDARY EDUCATION 06/09//2009 5/4/2013 GRADUATED 2002 NONE
NONE N/A N/A N/A N/A N/A N/A
TRADE
COURSE PHILIPPINE ELECTRONICS COMMUNICATION
COLLEGE
INSTITUTE OF TECHNOLOGY
BACHELOR OF ELEMENTARY EDUCATION 06/15/2014 05/29/2018 GRADUATED 2017 NONE
GRADUATE STUDIES NONE N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)
SIGNATURE DATE 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 applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity
LET (LICENSURE EXAMINATION FOR TEACHER) 81.20 03/25/2018 CAGAYAN DE ORO CITY 1655436 10/26/24
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
28. INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
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)
Department of education Division of Agusan
08/29/2022 10/14/2022 TEACHER 11-1 Substitute Y
del Norte 27,000.00
1/10/2020 06/30/2020 PSB-ASSSITANT TEACHER LAS NIEVES DISTRICT 2 8000.00 N/A Contractual Y
04/20/2011 05/24/2013 BAG RECEIVER CELEBES COCONUT CORPORATION 8000.00 N/A Regular N
(Continue on separate sheet if necessary)
SIGNATURE DATE 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 / NATURE OF WORK
From To
NONE 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 ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To
ENGLISH LANGUAGE SKILLS TRAINING PROGRAM 2/9/2019 09'30/2019 100.0 Technical Education and Skills Authority
(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 literate, Photography N/A N/A
(Continue on separate sheet if necessary)
SIGNATURE DATE 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
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? ________________________________
Finished Contract
________________________________
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
MANINGALAO, LAS NIEVES AGUSAN DEL the last 6 months
RICARDO C. BURDEOS NORTE
9385662115 3.5 cm. X 4.5 cm
(passport size)
LINGAYAO, LAS NIEVES, AGUSAN DEL
MELINA A. AJESTA NORTE
9079967882 With full and handwritten
name tag and signature over
printed name
GLENN Q. LARAN DANKIAS, BUTAUN CITY 9700281951
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete or photocopied picture
is not acceptable
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 administrative/criminal case/s PHOTO
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.: 1655436
Signature (Sign inside the box)
Date/Place of Issuance: 06/25/2018/BUTUAN CITY
Date accomplised Right Thumbmark
SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.
MARIA CORAZON C. PLASABAS, MPA
Person Administering Oath
CS FORM 212 (Revised 2017), Page 4 of 4
