CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

1. CS ID No. (Do

I. PERSONAL INFORMATION
2. SURNAME VANZUELA
NAME EXTENSION (JR., SR
FIRST NAME RUDYLEN JOY

MIDDLE NAME SAMACO

3. DATE OF BIRTH
(mm/dd/yyyy) 12/30/2001 16. CITIZENSHIP
✘ Filipino Dual Citizenship

by birth
4. PLACE OF BIRTH QUEZON CITY If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male ✘ Female

17. RESIDENTIAL ADDRESS BLOCK 37 LOT 13 LI

6 CIVIL STATUS ✘ Single Married
House/Block/Lot No. S
Widowed Separated
MALIGAYA FELICIANO BRGY. PA
Other/s:
Subdivision/Village Ba
NOVALICHES QUEZON CITY METR
7. HEIGHT (m) 1.51
City/Municipality Pr
8. WEIGHT (kg) 38 ZIP CODE

18. PERMANENT ADDRESS BLOCK 37 LOT 13 LI

9. BLOOD TYPE
House/Block/Lot No. S
MALIGAYA FELICIANO BRGY. PA
10. GSIS ID NO.
Subdivision/Village Ba
NOVALICHES, QUEZON CITY
11. PAG-IBIG ID NO.
City/Municipality Pr

12. PHILHEALTH NO. ZIP CODE 1118

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 20. MOBILE NO. +6397566652

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) vanzuelarudylen@gmail.co
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME VANZUELA

NAME EXTENSION (JR., SR)
FIRST NAME RODRGIO
 MIDDLE NAME KELISTE

25. MOTHER'S MAIDEN NAME

SURNAME SAMACO

FIRST NAME MARIZA

MIDDLE NAME COQUILLA (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

ELEMENTARY LAGRO ELEMENTARY SCHOOL

SECONDARY /
VOCATIONAL LAGRO HIGH SCHOOL GRADE 11

TRADE
COURSE
COLLEGE

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE AUGUS

CS FORM
L DATA SHEET

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Dual Citizenship

by birth by naturalization
Pls. indicate country:

LILY ST.
Street
BRGY. PASONG PUTIK
Barangay
METRO MANILA
Province

LILY ST.
Street
BRGY. PASONG PUTIK
Barangay
METRO MANILA
Province

+6397566652

vanzuelarudylen@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

 (Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2014

PRESENT

parate sheet if necessary)

AUGUST 05, 2019

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 ap
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

(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
 (Continue on separate sheet if necessary)

SIGNATURE DATE AUGUST 05, 2019

CS FORM 212 (Revised 20

 LICENSE (if applicable)

Date of
Validity

arate sheet if necessary)

GOV'T
SERVICE

(Y/
N)
arate sheet if necessary)

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

(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
 (Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

VERBAL AND WRITTEN COMMUNICATION 1ST PLACE IN DISTRICT MEET STANDARD DANCESPORT

PUBLIC SPEAKING 3RD PLACE IN DIVISION MEET STANDARD DANCESPORT

LONG PATIENCE AND UNDERSTANDING 6TH PLACE IN UP DILIMAN 6TH DANCESPORT CUP COMPETITION STANDARD

(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)

eparate sheet if necessary)

AUGUST 05, 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 ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? YES
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? ________________________________
________________________________
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
the last 6 months
MRS. MELANIE AQUINO 9328755502 3.5 cm. X 4.5 cm
(passport size)

MRS. ERLINDA PARAS 9239444698 With full and handwritten

name tag and signature over
printed name
MR. RAVINAL RAVIS JR. 9066436749
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:

ID/License/Passport No.:
Signature (Sign inside the box)
AUGUST 05, 2019
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 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