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 aga
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

I. PERSONAL INFORMATION
2. SURNAME N I C O LAS
FIRST NAME THELMA NAME EXTENSION

MIDDLE NAME DE VERA

3. DATE OF BIRTH
(mm/dd/yyyy) O7/28/1970 16. CITIZENSHIP
✘ Filipino Dual Citizenship
✘ by birth by
4. PLACE OF BIRTH BAGUIO CITY If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS 589 MENESE

Widowed Separated House/Block/Lot No. S

Other/s: TONTO
Subdivision/Village Ba
7. HEIGHT (m) 1.58496M LINGAYEN PANG
City/Municipality Pr
8. WEIGHT (kg) 56KG ZIP CODE 2041

9. BLOOD TYPE "A"

18. PERMANENT ADDRESS 589 MENESE
House/Block/Lot No. S

10. GSIS ID NO. CM498102 TONTO

Subdivision/Village Ba
LINGAYEN
11. PAG-IBIG ID NO. 121030604673
City/Municipality Pr

12. PHILHEALTH NO. 190007105030 ZIP CODE

2401
13. SSS NO. 3390837715 19. TELEPHONE NO. N/A

14. TIN NO. 913-728-361 20. MOBILE NO. 09422607428

15. AGENCY EMPLOYEE NO. 05187 21. E-MAIL ADDRESS (if any) tdvnicolas@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME NICOLAS 23. NAME of CHILDREN (Write full name and list all)

FIRST NAME ISAGANI LAURENCE ALPHA PRINCESS JOAN DE VERA NICOLAS

MIDDLE NAME DEGUZMAN ARKE ENGEL MARX DE VERA NICOLAS

OCCUPATION ARBITER ARTEMIS PRINCESS NICOLE DE VERA NICOLAS

EMPLOYER/BUSINESS NAME NATIONAL LABOR RELATIONS COMMISSION ANGELO LEX MIKHAIL DE VERA NICOLAS

BUSINESS ADDRESS PPSTTA BLDG. BANAWE, QUEZON CITY N/A

TELEPHONE NO. 075-522-5 075-522-5502

24. FATHER'S SURNAME DE VERA
FIRST NAME RODRIGO
MIDDLE NAME ROSARIO
25. MOTHER'S MAIDEN NAME

SURNAME DE VERA
FIRST NAME CONSOLACION
MIDDLE NAME INFANTE (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 BOGTONG ELEMENTARY SCHOOL PRIMARY N/A

SECONDARY
VOCATIONAL / PERPETUAL HELP COLLEGE HIGH SCHOOL N/A

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

TRADE
COURSE LYCEUM NORTH WESTERN
COLLEGE BSEED N/A
UNIVRSITY
INTERNATIONAL ACADEMY OF
GRADUATE STUDIES MANAGEMENT AND ECONOMICS(i- MBA N/A
AME)
(Continue on separate sheet if necessary)

SIGNATURE DATE 04/30/2017 CS FORM 212 (Re

L DATA SHEET
rience Sheet shall cause the filing of administrative/criminal case/s against the person

EFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR) N/A

Dual Citizenship

by naturalization

Pls. indicate country:

MENESES STREET
Street
TONTON EAST
Barangay
PANGASINAN
Province
2041
MENESES STREET
Street
TONTON EAST
Barangay
PANGASINAN
Province

N/A

09422607428

tdvnicolas@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

1/23/1990

10/17/1992

3/29/1994

11/4/1995

N/A

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

1982 DIPLOMA
 1986 DIPLOMA

N/A N/A

1993 DIPLOMA

2005 DIPLOMA

parate sheet if necessary)

CS FORM 212 (Revised 2017), Page1 of 4

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (if app
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

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 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

P16,026.00
09/01/1998 12/31/1999 LEG. COMMITTEE RESEARCHER HOUSE OF REPRESENTATIVES,CONGRESS /m N/A CO-TERMINUS

P17,629.00
01/01/2000 06/30/2001 LEG. COMMITTEE RESEARCHER HOUSE OF REPRESENTATIVES,CONGRESS m N/A CO-TERMINUS

P18,510.00
07/01/2001 09/30/2002 LEG. COMMITTEE RESEARCHER HOUSE OF REPRESENTATIVES,CONGRESS m N/A CONTRACTUAL

16,792.00/
10/01/2002 12/31/2006 LEG. STAFF OFFICER IV HOUSE OF REPRESENTATIVES,CONGRESS m N/A CONTRACTUAL

HOUSE OF REPRESENTATIVES,CONGRESS P16,792.00

1/1/2007 6/30/2007 LEG. STAFF OFFICER IV OFFICE OF CONG. A. ESPINO JR /m N/A CO-TERMINUS

HOUSE OF REPRESENTATIVES, CONGRESS, P18,471.00

7/1/2007 7/31/2007 LEG.STAFF OFFICER IV OFFICE OF CONG. A. ESPINO JR /m N/A CONTRACTUAL
OFFICE OF THE CITY MAYOR, HON. EDUARDO P25,000.00
7/1/2007 12/31/2007 CONSULTANT V. ROQUERO, SAN JOSE DEL MONTE /m N/A CONTRACTUAL
BULACAN
OFFICE OF THE CITY MAYOR, HON.
25,000.00/
07/12/008 12/31/2008 CONSULTANT EDUARDO V. ROQUERO, SAN JOSE N/A CONTRACTUAL
m
OFFICEDEL
OF MONTE BULACAN
THE CITY MAYOR, HON.
25,000.00/ CONTRACTU
1/1/2009 8/31/2009 CONSULTANT EDUARDO V. ROQUERO, SAN JOSE
m N/A AL
DEL MONTE BULACAN
OFFICE OF THE CITY MAYOR, SAN 20,000.00/
9/1/2009 12/31/2009 CONSULTANT N/A CONTRACTUAL
PEDRO m
OFFICE OF THE CITY MAYOR, SAN 15,000.00/
1/1/2010 6/30/2010 CONSULTANT N/A CONTRACTUAL
PEDRO m
JOINT COMMITTEE ON DANGEROUS
15,000.00/
7/1/2010 12/31/2010 CONSULTANT DRUGS, CONGRESSMAN ORLANDO N/A CONTRACTUAL
m
FUA
OFFICE OF THE CITY MAYOR, HON. 37,736.50/
1/1/2011 12/31/2011 EXECUTIVE ASSISTANT V N/A CO-TERMINUS
JAMES GORDON, JR m
OFFICE OF THE CITY MAYOR, HON. 39,473.00/
1/1/2012 12/31/2012 EXECUTIVE ASSISTANT V N/A CO-TERMINUS
JAMES GORDON, JR m
OFFICE OF THE CITY MAYOR, HON. 39,473.00/
1/1/2013 6//30/2013 EXECUTIVE ASSISTANT V N/A CO-TERMINUS
JAMES GORDON, JR m
OFFICE OF THE MAYOR, HON.
15,000.00/ CO-
7/1/2013 12/31/2013 CONSULTANT REYNALDO PEDRO, SAN JOSE DEL N/A
m TERMINUS
MONTE
OFFICE BULACAN
OF THE MAYOR, HON.
15,000,00/ CO-
1/1/2014 12/31/2014 CONSULTANT REYNALDO PEDRO, SAN JOSE DEL N/A
m TERMINUS
MONTE
OFFICE BULACAN
OF THE MAYOR, HON.
15,000.00/ CO-
1/1/2015 12/31/2015 CONSULTANT REYNALDO PEDRO, SAN JOSE DEL N/A
m TERMINUS
MONTE BULACAN
OFFICE OF THE MAYOR, HON. REYNALDO 15,000.00/
1/1/2016 6/30/2016 CONSULTANT
PEDRO, SAN JOSE DEL MONTE BULACAN
N/A CO-TERMINUS
m
HOUSE OF REPRESENTATIVES, OFFICE OF 36,409.00/
1/1/2016 12/31/2016 POL. AFFAIRS OFFICER III
CONG. AMADO. T ESPINO. JR,
SG 19 CO-TERMINUS
m
HOUSE OF REPRESENTATIVES, OFFICE OF 39,670.00/
1/1/2017 PRESENT POL. AFFAIRS OFFICER III
CONG. AMADO. T ESPINO. JR,
SG 19 CO-TERMINUS
m
 (Continue on separate sheet if necessary)

SIGNATURE DATE 04/30/2017 CS FORM 212 (Revised 2017), P

 LICENSE (if applicable)

Date of
Validity

N/A

ate sheet if necessary)

GOV'T
SERVICE

(Y/
N)
Y

Y
ate 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 / N
From To

NGO AREA BASED STANDARD NETWORK(ABSNET), BULACAN CHAPTER 06/30/2008 06/30/2008 24.0 ME

CITIZENS MOVEMENT FOR SERVICE AND GOOD GOVERNANCE

09/25/2008 09/25/2008 24.0 ME
FOUNDATION
LIVELIHOOD ENTERPRENEURIAL ADVANCEMENT AND DEVELOPMENT
09/25/2008 09/25/2008 24.0 ME
FOUNDATION

PARENTS-TEACHERS AND COMMUNITY ASSOCIATION 06/30/2009 06/30/2009 24.0 ME

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

(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/ SP
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To
COMMITTEE ON CONSTITUTIONAL AMENDMENTS: PUBLIC HOUSE OF R
02/15/2017 02/15/2017 24 TECHNICAL
CONSULTATION
OFFICE ADMINISTRATION SEMINAR: ADMINISTRATIVE PROFESSIONALS
10/20/2007 10/20/2007 24 TECHNICAL UP
COPING WITH THE 21ST CENTURY WORKPLACE
EDUCATORS SEMINAR 10/13/2007 10/13/2007 24 TECHINCAL METANO
SYMPOSIUM ON RE-ENGNEERING THE BUREAUCRACY FOR BETTER
9/21/2000 9/21/2000 24.0 TECHNICAL HOUSE OF RE
GOVERNANCE
VOLUNTE
SUMMIT AGAINST GRAFT AND CORRUPTION:AN NGO INITIATIVE 5/30/2000 5/30/2000 24.0 TECHNICAL
C

ANTI-CORRUPTION THRUST OF THE ESTRADA ADMINISTRATION 10/25/1998 10/25/1998 24.0 TECHNICAL UP COLLEG

COURSE ON SEXUAL HARRASSMENT 11/14/1998 11/14/1998 24.0 TECHNICAL HOUSE OF RE

FEDERALISM 101: CONCEPTS, FORUMS AND BOUNDARIES 8/2/2016 8/2/2016 24.0 TECHNICAL HOUSE OF RE

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSH
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)
 COOKING N/A

COMMUNITY ORGANIZING

N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 04/30/2017

EOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

MEMBER

MEMBER

MEMBER

MEMBER

N/A

te sheet if necessary)

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

CONDUCTED/ SPONSORED BY
(Write in full)

HOUSE OF REPRESENTATIVES,QUEZON
CITY
UP-ISSI, UP DILIMAN

METANOIA GABAY ARAL INC./UP

HOUSE OF REPRESENTATIVES,QUEZON CITY

VOLUNTEERS AGAINST CRIMES AND

CORRUPTION(VACC)

UP COLLEGE OF PUBLIC ADMINISTRATION

HOUSE OF REPRESENTATIVES,QUEZON CITY

HOUSE OF REPRESENTATIVES,QUEZON CITY

te sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION

(Write in full)
 N/A

te sheet if necessary)

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:
________________________________
YES ✘ NO
35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
YES
________________________________
✘ NO
________________________________
b. Have you been criminally charged before any court?
If YES, give details:
________________________________
Date Filed:
YES ✘ NO
________________________________
Status of Case/s:

36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation
by any court or tribunal?
YES If✘YES,
NO 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? ________________________________
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 If YES,
✘ NOgive 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? If YES, give details:
39. Have you acquired the status of an immigrant or permanent resident of another country?
YES If YES,
✘ NOgive details (country):

YES ✘ NO
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:
b. Are you a person with disability?
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
ATTY. ORALNDO B. FUA,SR QUEZON CITY 9175033066 3.5 cm. X 4.5 cm
(passport size)

HON. AMADO T. ESPINO JR. DUPO,BINMALEY,PANGASINAN 9174855004 With full and handwritten
name tag and signature over
printed name
REYNALDO SAN PEDRO SAN JOSE DEL MONTE BULACAN 9178370304
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: HOUSE OF REPRESENTATIVES ID

ID/License/Passport No.: 05187

Signature (Sign inside the box)
04/30/2017
Date/Place of Issuance: 2016/HOUSE OF REPRESENTATIVES
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

 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