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 ag

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.
I. PERSONAL INFORMATION
2. SURNAME PIAMONTE
FIRST NAME NICKO
MIDDLE NAME GARCIA
3. DATE OF BIRTH
(mm/dd/yyyy) 12/10/1995 16. CITIZENSHIP ✘ Filipino

4. PLACE OF BIRTH BRGY. BARBO, DULAG, LEYTE If holder of dual citizenship,

please indicate the details.

5. SEX ✘ Male Female

✘ Single Married 17. RESIDENTIAL ADDRESS

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

Other/s:
Subdivision/Village
7. HEIGHT (m) 166.5 DULAG
City/Municipality
8. WEIGHT (kg) 72 ZIP CODE 65
18. PERMANENT ADDRESS
9. BLOOD TYPE O House/Block/Lot No.

10. GSIS ID NO. N/A Subdivision/Village

11. PAG-IBIG ID NO. N/A DULAG

City/Municipality

12. PHILHEALTH NO. N/A ZIP CODE 65

13. SSS NO. N/A 19. TELEPHONE NO. N
14. TIN NO. N/A 20. MOBILE NO. 0926-7
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) nickopiamonte1
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME N/A
MIDDLE NAME

OCCUPATION N/A
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME PIAMONTE
NAME EXTENSION (JR., SR) JR.
FIRST NAME PATROCENIO
 MIDDLE NAME CAGARA
25. MOTHER'S MAIDEN NAME

SURNAME GARCIA
FIRST NAME VIRGINIA
MIDDLE NAME AGUILLON (Continue on separ

III. EDUCATIONAL BACKGROUND

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

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

ELEMENTARY DULAG CENTRAL SCHOOL PRIMARY EDUCATION 2002

SECONDARY /
VOCATIONAL DULAG NATIONAL HIGH SCHOOL HIGH SCHOOL 2008

N/A N/A
TRADE
BACHELOR OF SCIENCE IN
COURSE
COLLEGE LEYTE COLLEGES 2012
CRIMINOLOGY
GRADUATE STUDIES N/A N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE
L DATA SHEET
t shall cause the filing of administrative/criminal case/s against the person concerned.

OMPLISHING THE PDS FORM.

1. CS ID No. (Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR) N/A

✘ Filipino Dual Citizenship

by birth by naturalization

Pls. indicate country:

House/Block/Lot No. Street

SUNGI
Subdivision/Village Barangay
DULAG LEYTE
City/Municipality Province

6505

House/Block/Lot No. Street

SUNGI
Subdivision/Village Barangay
LEYTE
City/Municipality Province

6505
N/A
0926-723-2977
nickopiamonte1234@gmail.com

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

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

HIGHEST LEVEL/ SCHOLARSHIP/

PERIOD OF ATTENDANCE YEAR
UNITS ACADEMIC
GRADUATED
EARNED HONORS
(if not graduated) RECEIVED
To

GRADUATE
2008 2008 N/A
D
GRADUATE
2012 2012 N/A
D
N/A N/A N/A
GRADUATE
2016 2016 N/A
D
N/A N/A N/A N/A
eparate sheet if necessary)

DATE JANUARY 15, 2019

CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/
RATING DATE OF EXAMINATION /
CSEE BARANGAY ELIGIBILITY / DRIVER'S PLACE OF EXAMINATION / CONFERMENT
(If Applicable) CONFERMENT
LICENSE

CRIMINOLOGIST LICENSURE EXAMINATION 79. 05 JUNE 10-12, 2018 LEYTE NATIONAL HIGH SCHO

(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
DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) POSITION TITLE MONTHLY
(Write in full/Do not SALARY
(Write in full/Do not abbreviate)
abbreviate)
From To

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

 (Continue on separate sheet if necessary)

SIGNATURE DATE JA
 LICENSE (if applicable)
PLACE OF EXAMINATION / CONFERMENT
NUMBER Date of
Validity

LEYTE NATIONAL HIGH SCHOOL 0164900 12/7/2018

on separate sheet if necessary)

ould be indicated in the attached Work Experience sheet.

SALARY/ JOB/ PAY GOV'T SERVICE
GRADE (if
STATUS OF
applicable)& STEP
(Format "00-0")/ APPOINTMENT
INCREMENT (Y/ N)

N/A N/A N/A

on separate sheet if necessary)

JANUARY 15, 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 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/
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To

N/A N/A N/A N/A 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)

COMPUTER LITERATE N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE J
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

N/A

eparate sheet if necessary)

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

CONDUCTED/ SPONSORED BY
(Write in full)

N/A
eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

N/A

eparate sheet if necessary)

JANUARY 15, 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? YES ✘ NO

b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘ NO

If YES, give details:

________________________________

a. Have you ever been found guilty of any administrative offense? YES ✘ NO
35.

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:
YES ✘ NO
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:
________________________________
YES ✘ 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 If YES, give details:
phased out (abolition) in the public or private sector? ________________________________
YES ✘ NO
________________________________
38. a. Have you ever been a 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 the
last election to promote/actively campaign for a national or local candidate? YES 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):

40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA YES ✘ NO
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?
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
the last 6 months
ROCHEN SHAIRA E. DARGANTES BRGY. MASLOG, LAWAAN, E. SAMAR 0936-934-3530 3.5 cm. X 4.5 cm
(passport size)

JESSA A. SASI BRGY. 01, BALANGIGA, E. SAMAR 0919-826-8854 With full and handwritten
name tag and signature over
printed name
ALLEN M. PANZO BRGY. SUNGI, DULAG, LEYTE 0967-251-7849
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
is not acceptable
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: N/A
ID/License/Passport No.: N/A Signature (Sign inside the box)
JANUARY 15, 2019
Date/Place of Issuance: N/A 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