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
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.

I. PERSONAL INFORMATION
2. SURNAME BERGADO

FIRST NAME LODIVINIA

MIDDLE NAME CANDARE

3. DATE OF BIRTH
(mm/dd/yyyy) January 29,1952 16. CITIZENSHIP ✘ Filipino Dual Citize

4. PLACE OF BIRTH barangay Hugo Perez,Trece Martires City If holder of dual citizenship,

please indicate the details.

5. SEX Male ✘ Female

Single Married 17. RESIDENTIAL ADDRESS Purok 3, Barangay Hugo Perez

6 CIVIL STATUS
✘ Widowed Separated Trece Martires City

Other/s:

7. HEIGHT (m) 163.0

8. WEIGHT (kg) 70.0 ZIP CODE 4109

18. PERMANENT ADDRESS Purok 3, Barangay Hugo Perez

9. BLOOD TYPE A'B
Trece Martires City

10. GSIS ID NO.

11. PAG-IBIG ID NO.

12. PHILHEALTH NO. ZIP CODE 4109

13. SSS NO. 19. TELEPHONE NO. N/A

14. TIN NO. 169-452-969-000 20. MOBILE NO. 0977-371-2601

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) bergadolodivi64@ya
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME BERGADO 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR N/A RAYMOND C. BERGADO
FIRST NAME RODOLFO

MIDDLE NAME SOLANO GLEN C. BERGADO

OCCUPATION DECEASED RODOLFO C. BERGADO

EMPLOYER/BUSINESS NAME ELAINE B. GUMASING

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME CANDARE

NAME EXTENSION (JR., SR) N/A
FIRST NAME AGUSTIN

MIDDLE NAME SALAZAR

25. MOTHER'S MAIDEN NAME LAECHON

SURNAME CANDARE

FIRST NAME MONICA

MIDDLE NAME IROG (Continue on separate sheet

III. EDUCATIONAL BACKGROUND

26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE

LEVEL
(Write in full) (Write in full)
From To

ELEMENTARY TRECE ELEMENTARY SCHOOL ELEMAENTARY ### ###

SECONDARY TRECE NATIONAL HIGH SCHOOL SECONDARY 6/8/1964 ###

VOCATIONAL /

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

TRADE
COURSE
COLLEGE GREGORY BUSINESS COLLEGE TERTIARY ### ###

GRADUATE STUDIES N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE
AL DATA SHEET
Experience Sheet shall cause the filing of administrative/criminal case/s against the person

S) BEFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

✘ Filipino Dual Citizenship

✘ by birth by naturalization

Pls. indicate country:

Cavite

4109

Cavite

N/A

0977-371-2601

bergadolodivi64@yahoo.com

23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

RAYMOND C. BERGADO JUNE 9,1972

GLEN C. BERGADO JANUARY 6,1981

RODOLFO C. BERGADO APRIL 25,1988
ELAINE B. GUMASING SEPTEMBER 28,1983

(Continue on separate sheet if necessary)

HIGHEST LEVEL/ SCHOLARSHIP/

YEAR
UNITS ACADEMIC
GRADUATED
EARNED HONORS
(if not graduated) RECEIVED

GRADUATE 1964 N/A

GRADUATE 1969 N/A

 N/A N/A N/A

GRADUATE 1971 N/A

N/A N/A N/A

on separate sheet if necessary)

SEPTEMBER 5,2017

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

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

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

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

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

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

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

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
SALARY/
Experience sheet. GOV'T
JOB/ PAY SERVICE
28. INCLUSIVE DATES GRADE (if
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY applicable)&
MONTHLY STATUS OF
(Write in SALARY
STEP
APPOINTMENT
(Format "00-
(Write in full/Do not abbreviate) full/Do not abbreviate) 0")/
From To INCREMEN (Y/
T N)
SEPTEMBER/09/2
MAY/15/2001 008 OFFICE STAFF KAABAY 3000.00 CASUAL N/A
SEPTEMBER/09/20 PRESENT
08 OFFICE STAFF PESO OFFICE 4000.00 CASUAL N/A
S
N/A N/A N/A N/A N/A N/A N/A N/A

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

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(Continue on separate sheet if necessary)

SIGNATURE DATE SEPTEMBER 5,2017

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
From To

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

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

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

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

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

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

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 ( Managerial/ CONDUCTED/ SPONS
NUMBER OF HOURS
PROGRAMS (Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To
DEPARTME
NATIONAL PESO CONGRESS 10/13/2017 10/15/2017 24HOURS TECHNICAL
EMP
DEPARTME
ORIENTATION ON GUIDELINE ON INTERGRATED LIVELIHOOD 6/23/2014 6/25/2014 32HOURS TECHNICAL
EMP
DEPARTME
ORIENTATION ON TVET SYSTEM DUAL TECH/APPRENTICESHIP 0624/2017 6/24/2017 8HOURS TECHNICAL
EMP
CONDUCTING ORIENTATION SERVICE ON LABOR EDUCATION DEPARTME
2/21/2011 2/21/2011 8HOURS TECHNICAL
FOR COLLEGE GRADUATE STUDENTS EMP
DEPARTME
CAREER INFORMATION GUIDANCE COUSELING 2/28/2011 2/28/2011 8HOURS TECHNICAL
EMP
DEPARTME
MID-YEAR PERFORMANCE ASSESMENT 6/17/2011 6/17/2011 8HOURS TECHNICAL
EMP
N/A N/A N/A N/A N/A

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

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

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

TYPING N/A
READING BOOKS N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE Septe

CS FORM 2
ERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

N/A

N/A

N/A

N/A

N/A

N/A

N/A
e on separate sheet if necessary)
RAINING PROGRAMS ATTENDED
aken for the last five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

DEPARTMENT OF LABOR AND

EMPLOYMENT
DEPARTMENT OF LABOR AND
EMPLOYMENT
DEPARTMENT OF LABOR AND
EMPLOYMENT
DEPARTMENT OF LABOR AND
EMPLOYMENT
DEPARTMENT OF LABOR AND
EMPLOYMENT
DEPARTMENT OF LABOR AND
EMPLOYMENT
N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

e on separate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION

(Write in full)

N/A
 N/A

N/A

N/A

N/A

N/A

N/A
e on separate sheet if necessary)

September 5,2017
CS FORM 212 (Revised 2017), Page 3 of 4
 34. Are you related by consanguinity or affinity to the appointing or recommending
authority,
chief or to the
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:
________________________________
N/A
________________________________
b. Have you been criminally charged before any court? YES NO
If YES, give details:
________________________________
Date Filed: N/A
________________________________
Status of Case/s: N/A

36. Have you ever been convicted of any crime or violation of any law, decree,
YES ✘ NO
ordinance or regulation by any court or tribunal?
If YES, give details:
________________________________N/A
________________________________
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? ________________________________ N/A
________________________________
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: N/A

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

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

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
VERONICA G. DE SAGUN SAN AGUSTIN N/A 3.5 cm. X 4.5 cm
(passport size)

With full and handwritten

name tag and signature over
printed name

Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a or photocopied picture
is not acceptable
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 PHOTO
misrepresentation made in this document and its attachments shall cause the filing of
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:

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

Date/Place of Issuance:
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 of 4