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
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 BALONGOY
NAME EXTENSION (JR., SR
FIRST NAME JANNEIL

MIDDLE NAME JERUSALEM

3. DATE OF BIRTH
(mm/dd/yyyy) 12/22/1993 16. CITIZENSHIP
✘ Filipino Dual Citizenship
✘ by birth by
4. PLACE OF BIRTH DAPITAN CITY If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Female
✘ Male

17. RESIDENTIAL ADDRESS 531

6 CIVIL STATUS ✘ Single Married
House/Block/Lot No. S
Widowed Separated
PUROK GREEN VALLEY TU
Other/s: Subdivision/Village Ba
DIPOLOG CITY ZAMBOANG
7. HEIGHT (m) 1.6m
City/Municipality Pr
8. WEIGHT (kg) 75kg ZIP CODE

18. PERMANENT ADDRESS 531

9. BLOOD TYPE O
House/Block/Lot No. S
PUROK GREEN VALLEY TU
10. GSIS ID NO.
Subdivision/Village Ba
DIPOLOG CITY ZAMBOANG
11. PAG-IBIG ID NO. 121153635336
City/Municipality Pr

12. PHILHEALTH NO. ZIP CODE

13. SSS NO. 10-1323728-3 19. TELEPHONE NO.

14. TIN NO. 20. MOBILE NO. 09196463539

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) jjbalongoy@gmail.com
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 BALONGOY (deceased)

NAME EXTENSION (JR., SR)
FIRST NAME JOCI
 MIDDLE NAME VIOLANDA

25. MOTHER'S MAIDEN NAME

SURNAME JERUSALEM

FIRST NAME NARCISA

MIDDLE NAME EMPRESTITO (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 DIPOLOG PILOT DEMONSTRATION SCHOOL 6/1/2000 3/31/2006

ZAMBOANGA DEL NORTE NATIONAL HIGH

SECONDARY /
VOCATIONAL SCHOOL
6/1/2006 3/31/2010

TRADE
COURSE
COLLEGE MINDANAO STATE UNIVERSITY - Main Campus BS SOCIAL WORK 6/1/2010 3/31/2015

UNIVERSITY OF SOUTHERN PHILIPPINES,

GRADUATE STUDIES
FOUNDATION
MS SOCIAL WORK 06/012018 -

(Continue on separate sheet if necessary)

SIGNATURE DATE July 2

CS FORM
L DATA SHEET
erience 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)

Dual Citizenship

by naturalization
Pls. indicate country:

Street
TURNO
Barangay
ZAMBOANGA DEL NORTE
Province

Street
TURNO
Barangay
ZAMBOANGA DEL NORTE
Province

09196463539

jjbalongoy@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

 (Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2006

2010

MSU-SASE
2015 SCHOLAR

parate sheet if necessary)

July 29, 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

BOARD EXAM FOR SOCIAL WORKERS 82.3 JULY CAGAYAN DE ORO CITY 0023812

JO1-18-
NON-PROFESSIONAL DRIVER'S LICENSE 4/4/2018 DIPOLOG CITY
001899

(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

CHILDREN DEVELOPMENT CENTER MARAWI,

6/1/2015 3/31/2017 ELEMENTARY TEACHER INC. 8000.00 N/A CONTRACTUAL

CITY SOCIAL WELFARE AND DEVELOPMENT CITY SOCIAL WELFARE AND

9/12/2017 PRESENT OFFICE STAFF/DISTRICT IN-CHARGE 10000.00 N/A JOB ORDER
DEVELOPMENT OFFICE
 (Continue on separate sheet if necessary)

SIGNATURE DATE JULY 29, 2019

CS FORM 212 (Revised 20

 LICENSE (if applicable)

Date of
Validity

12/22/2019

12/22/2022

arate sheet if necessary)

GOV'T
SERVICE

(Y/
N)
N

Y
arate sheet if necessary)

JULY 29, 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 / NATURE OF WORK
From To
CITY SOCIAL WELFARE AND DEVELOPMENT OFFICE/CAGAYAN DE ORO
4/1/2014 9/30/2014 1000.0 INTERN
CITY

(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/ SPONSORED BY
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To
CITY DISASTER AND RISK REDUCTION
PSYCHOLOGICAL FIRST AID TRAINING OF TRAINERS 7/18/2019 7/20/2019 24 Hours TECHNICAL
OFFICE/ DEPARTMENT OF EDUCATION
CITY DISASTER AND RISK REDUCTION OFFICE/
CAMP COORDINATION AND CAMP MANAGEMENT TRAINING OF TRAINERS 7/22/2019 7/26/2019 40 Hours TECHNICAL DEPT. OF SOCIAL WELFARE AND DEVELOPMENT
PROTECTING CHILDREN IS EVERYONE'S BUSINESS: A FORUM ON THE CHILD FUND PHILIPPINES/ ZAMBOANGA DEL
12/14/2018 12/14/2018 8 Hours TECHNICAL
PROTECTION OF CHILDREN IN THE TOURISM INDUSTRY NORTE FEDERATION OF PARENTS ASSOC.

CAPACITY BUILDING FOR BARANGAY AND CITY COUNCIL FOR THE PROTECTION
CHILD FUND PHILIPPINES/ ZAMBOANGA DEL
OF CHILDREN IN FORMULATING INNOVATIVE PROGRAMS, PROJECTS AND 10/22/2018 10/23/2018 16 Hours TECHNICAL
NORTE FEDERATION OF PARENTS ASSOC.
ACTIVITIES FOR CHILDREN

TRAINING WORKSHOP ON PROTECTION MAINSTREAMING AND INFORMATION UNITED NATIONS HIGH COMMISSIONER FOR
9/10/2018 9/14/2018 40 Hours TECHNICAL
MANAGEMENT REFUGEES PHILIPPINES
INTERNATIONAL ORGANIZATION FOR
CAMP COORDINATION AND CAMP MANAGEMENT TRAINING 9/12/2018 9/12/2018 8 Hours TECHNICAL
MIGRATION
SEMINAR ON COMPREHENSIVE LOCAL JUVENILE INTERVENTION PROGRAM DEPARTMENT OF SOCIAL WELFARE AND
7/31/2018 7/31/2018 8 Hours TECHNICAL
CUM PLANNING WORKSHOP DEVELOPMENT
NATIONAL ASSOCIATION FOR SOCIAL WORK
SEMINAR-WORKSHOP ON GENDER RESPONSIVE CASE MANAGEMENT FOR EDUCATION, INC./ DEPARTMENT OF SOCIAL WORK,
5/22/2018 5/26/2018 40 Hours TECHNICAL
SOCIAL WORK PRACTITIONERS COLLEGE OF PUBLIC AFFAIRS, MINDANAO STATE
UNIVERSITY-MAIN CAMPUS

DEPARTMENT OF SOCIAL WELFARE AND

TECHNICAL ASSISTANCE FORUM ON ADOPTION AND FOSTER CARE PROGRAM 4/25/2018 4/27/2018 24 Hours TECHNICAL
DEVELOPMENT

PASWI-ZAMBOANGA CITY CHAPTER ANNUAL CONFERENCE 2018 "LENS OF

PHILIPPINE ASSOCIATION OF SOCIAL
ONLINE SEXUAL EXPLOITATION OF CHILDREN: CHILD SEX TRAFFICKING AND 3/2/2018 3/3/2018 16 Hours TECHNICAL
WORKERS, INC. - ZAMBOANGA CITY CHAPTER
CHILD PORNOGRAPHY"

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

PHILIPPINE ASSOCIATION OF SOCIAL

WORKERS, INCORPORATED - ZANDIDAP
CHAPTER

(Continue on separate sheet if necessary)

SIGNATURE DATE JULY 29, 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? FINISHED CONTRACT
________________________________
________________________________
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
ARLENE O.JATICO STA. ISABEL, DIPOLOG CITY 9053383609 3.5 cm. X 4.5 cm
(passport size)

JOVENCIA D. ORILLA STA. FILOMENA, DIPOLOG CITY 9491301818 With full and handwritten
name tag and signature over
printed name
ALFRED D. AVENIDO SANTIAGO, ILIGAN CITY 9338688271
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: PRC ID

ID/License/Passport No.: 0023812

Signature (Sign inside the box)
JULY 29, 2019
Date/Place of Issuance: 04-08-2016/CAGAYAN DE ORO CITY
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