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 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 GOROSPE
NAME EXTENSION (JR., SR)
FIRST NAME DARREL
MIDDLE ADAON
NAME
3. DATE OF BIRTH
(mm/dd/yyyy)
21/01/2000 16. CITIZENSHIP
Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH BURGOS If holder of dual citizenship,
naturalization
please indicate the details.
Pls. indicate country:
5. SEX Male Female
Single Married
6 CIVIL STATUS 17. RESIDENTIAL ADDRESS House/Block/Lot No. Street
Widowed Separated BUDUAN
Subdivision/Village Barangay
Other/s:
7. HEIGHT (m) 1.73 BURGOS ILOCOS NORTE
City/Municipality Province
ZIP CODE
8. WEIGHT (kg) 77 2918
9. BLOOD TYPE B+ 18. PERMANENT ADDRESS
House/Block/Lot No. Street
10. GSIS ID NO. N/A BUDUAN
Subdivision/Village Barangay
11. PAG-IBIG ID NO. 121333502847 BURGOS ILOCOS NORTE
City/Municipality Province
12. PHILHEALTH NO. 05-025856811-4 ZIP CODE
2918
13. SSS NO. N/A 19. TELEPHONE NO.
14. TIN NO. 637-153-070 20. MOBILE NO. 09690152409
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) DATE OF BIRTH
(mm/dd/yyyy)
NAME EXTENSION (JR., SR) N/A
FIRST NAME
MIDDLE
NAME
OCCUPATION
EMPLOYER/BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.
24. FATHER'S SURNAME GOROSPE
NAME EXTENSION (JR., SR)
FIRST NAME DANILO
MIDDLE NAME PERUCHO
25. MOTHER'S MAIDEN NAME
SURNAME ADAON
FIRST NAME AMANCIA
MIDDLE NAME
LLAPITAN (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
HIGHEST
LEVEL/ YEAR SCHOLARSHIP/
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE
LEVEL UNITS GRADUATE ACADEMIC
(Write in full) (Write in full) D HONORS
EARNED
From To (if not RECEIVED
with
ELEMENTARY Burgos Central Elementary School Elementary 2006 2012 2012
Distinction
SECONDARY Burgos Agro-Industrial School Junior Highschool 2012 2016 2016 With Honor
VOCATIONAL /
TRADE COURSE
Ilocos Norte National Highschool Senior Highschool 2016 2018 2018 With Honor
COLLEGE Mariano Marcos State University BS in Electrical Engineering 2018 2022 2022
GRADUATE STUDIES
(Continue on separate sheet if necessary)
SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 1 of 4
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER LICENSE (if applicable)
RATING DATE OF EXAMINATION /
SPECIAL LAWS/ CES/ CSEE PLACE OF EXAMINATION / CONFERMENT Date
(If CONFERMENT NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE Applicable) of
Validit
y
Registered Electrical Engineer 76.70 April 25-26, 2023 University of Cordillera, Baguio City 0083770 01/21/2026
Ilocos Norte College of Arts and Trade, Laoag
NC II Oct. 27, 2017
City
(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.
INCLUSIVE DATES SALARY/ JOB/
28.
PAY GRADE
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY STATUS OF GOV'T SERVICE
(if
(Write in full/Do not (Write in full/Do not abbreviate) SALARY APPOINTMENT (Y/ N)
applicable)&
From To abbreviate) STEP (Format
"00-0")/
INCREMENT
10/02/2023 present Civil Aviation Authority of The 17,820.00 JG 10 Job Order
Firefighter I
Philippines
(Continue on separate sheet if necessary)
SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 2 of 4
INCLUSIVE DATES
29. NAME & ADDRESS OF ORGANIZATION NUMBER
(Write in (mm/dd/yyyy) POSITION / NATURE OF WORK
OF
full) From To HOURS
(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
Type of
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE NUMBER LD ( CONDUCTED/ SPONSORED BY
(Write in (mm/dd/yyyy) OF Managerial (Write in full)
full) HOURS /
From To Supervisor
y/
Technical/et
c)
Building wiring, Inspection and MMSU Pasilaw Extension Program 01/05/2021 10/31/2022 240 hrs Technical
Mariano Marcos State University
College on the Job Training (Design and Analysis of Electrical Plan) 07/2021 09/2021 Technical
Mariano Marcos State University
Senior Highschool on the Job Training 05/02/2018 04/27/2018 180 hrs Technical
Mariano Marcos State University
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
31. SPECIAL SKILLS and HOBBIES NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMBERSHIP IN
32. (Write in full) 33.
ASSOCIATION/ORGANIZATION
(Write in full)
Institute of Integrated Electrical Engineers
Computer Literate Region 1 Athletic Association Player (Soccer)
of the Philippines
MS WORD, MS EXCEL, MS POWERPOINT Palaro Player (Soccer)
Autocad SCUAA Player (Soccer)
Design and Analysis of Electrical Plan
Sports
(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, YES NO
a. within the third degree? YES NO
b. within the fourth degree (for Local Government Unit - Career Employees)? If YES, give details:
35. a. Have you ever been found guilty of any administrative YES NO
offense?
If YES, give details:
YES NO
b. Have you been criminally charged before any court?
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 YES NO
regulation by any court or tribunal? If YES, give details:
37. Have you ever been separated from the service in any of the following modes:
YES NO
resignation, retirement, dropped from the rolls, dismissal, termination, end of term,
If YES, give details:
finished contract or phased out (abolition) in the public or private sector?
38. a. Have you ever been a candidate in a national or local election held within the last
YES NO
year (except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period YES NO
before the last election to promote/actively campaign for a national or local If YES, give details:
candidate?
YES NO
39. Have you acquired the status of an immigrant or permanent resident of another
If YES, give details (country):
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:
YES NO
a. Are you a member of any indigenous group? If YES, please specify:
YES NO
b. Are you a person with disability?
If YES, please specify ID No:
c. Are you a solo YES NO
parent?
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
Tarsicius I. Bumagat within the last 6
Burgos, Ilocos Norte 09565093693 months
3.5 cm. X 4.5 cm
Wilson Miguel Sr.
Laoag City 09209686724 (passport size)
Salustiano D. Morales With full and handwritten
Laoag City 09328589964 name tag and signature
over printed name
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true,
Computer generated
correct and complete statement pursuant to the provisions of pertinent laws, rules and PHOTO
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
Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's
License, etc.)
PLEASE INDICATE ID Number and Date of Issuance
Government Issued ID: Driver's License
ID/License/Passport No.: A10-20-000593 Signature (Sign inside the
Date/Place of Issuance: Jan. 31, 2020: Batac City box) Date Right Thumbmark
Accomplished
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 of 4
