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 aga
the person 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 not fill up. For CSC

I. PERSONAL INFORMATION
2. SURNAME PACALSO

FIRST NAME ROMEO JR

MIDDLE NAME FLORIDA

3. DATE OF BIRTH
(mm/dd/yyyy) 2/15/1992 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by naturalizati
4. PLACE OF BIRTH BURGOS, LA UNION If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

✘ Single Married 17. RESIDENTIAL ADDRESS MB 057-C

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
BUHAO PUGUIS
Other/s:
Subdivision/Village Barangay
LA TRINIDAD BENGUET
7. HEIGHT (m) 1.65
City/Municipality Province
8. WEIGHT (kg) 67 ZIP CODE 2601
18. PERMANENT ADDRESS
9. BLOOD TYPE O+
House/Block/Lot No. Street
CENTRAL PALALI POBLACION
10. GSIS ID NO. NONE
Subdivision/Village Barangay
SABLAN BENGUET
11. PAG-IBIG ID NO. 121232537260
City/Municipality Province
12. PHILHEALTH NO. 04-025267777-3 ZIP CODE 2614

13. SSS NO. 34-7814844-9 19. TELEPHONE NO. NONE

14. TIN NO. 706-935-981 20. MOBILE NO. 09384550159

15. AGENCY EMPLOYEE NO.
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME
FIRST NAME
NONE 21. E-MAIL ADDRESS (if any) pacxcalso@gmail.com
NONE 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/d
NAME EXTENSION (JR., SR)
NONE

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME PACALSO O7/23/1961

FIRST NAME ROMEO SR

MIDDLE NAME PADSUYAN

25. MOTHER'S MAIDEN NAME

SURNAME FLORIDA 5/13/1965

FIRST NAME VIOLETA

MIDDLE NAME ORBIZTONDO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE LEVEL/
26. PERIOD OF ATTENDANCE YEAR
UNITS
LEVEL (Write in full) EARNED
GRADUATED
(Write in full) (if not
From To
graduated)
GRADUATE
ELEMENTARY PALALI ELEMENTARY SCHOOL PRIMARY 1998 2004 D 2004
VOCATIONAL / GRADUATE
SECONDARY SAINT LOUIS SCHOOL OF SABLAN SECONDARY 2004 2008 D 2008
ELECTRICAL INSTALLATION GRADUATE
TESDA CAR TRAINING CENTER
MAINTENANCE NC2 2012 2012 D 2012
CORDILLERA CAREER BACHELOR OF SCIENCE IN GRADUATE
COLLEGE TRADE 2013 2016 2016
COURSE DEVELOPMENT COLLEGE CRIMINOLOGY D
GRADUATE STUDIES NONE

(Continue on separate sheet if necessary)

SIGNATURE DATE September 20, 2019

CS FORM 212 (Revised 2017), P

se/s against

For CSC use only)

uralization

ry:

RTH (mm/dd/yyyy)

23/1961

13/1965

SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED

NONE

NONE

NONE

NONE
2019

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

RA 6506 82.6 JUNE 11-13, 2017 BAGUIO CITY 0148061

CAREER SERVICE PROFESSIONAL SAINT LOUIS UNIVERSITY, BAGUIO
82.1 3/12/2017
ELIGIBILTY CITY

(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/
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY PAY GRADE (if STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To

10/1/2018 PRESENT PATROLMAN PHILIPPINE NATIONAL POLICE ### 10 TEMP

(Continue on separate sheet if necessary)

SIGNATURE DATE SEPTEMBER 20, 2019

CS FORM 212 (Revised 2017), Pag
 LICENSE (if applicable)

Date of
Validity

2/15/2020

on separate sheet if necessary)

tion of duties should be indicated in the attached Work Experience sheet. GOV'T
SERVICE

(Y/
N)
Y

on separate 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
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (Write in
full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

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
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) From To Technical/etc)

PUBLIC SAFETY BASIC RECRUIT COURSE 10/1/2018 4/9/2019 960.0 TECHNICAL PHILIPPINE PUBLIC SAFETY COLLEGE

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 33.
(Write in full) (Write
in full)
COMPUTER LITERATE NONE PHILIPPINE NATIONAL POLICE
ELECTRICAL INSTALLATION AND
MAINTENANCE NC 2

(Continue on separate sheet if necessary)

SIGNATURE DATE SEPTEMBER 20, 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 theof bureau or office or to the person who has immediate supervision over you in the
chief
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:
________________________________
________________________________
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
YES ✘ NO
regulation 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 If YES, give details:
phased 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 YES ✘ NO
(except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
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 ✘ 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
a.
items:
Are you a member of any indigenous group? ✘ YES NO
If YES, please specify: KANKANA-EY/ IBALOI
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
LA 117, INSELBEG, LUBAS, LA the last 6 months
FAUSTA MANANENG TRINIDAD, BENGUET
9129603713 3.5 cm. X 4.5 cm
(passport size)
POBLACION, SABLAN,
ALFONSE CAISO BENGUET
9212105034 With full and handwritten
name tag and signature over
POBLACION, SABLAN, printed name
ARTHUR DE LEON BENGUET
9183203931
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct or photocopied picture
is not acceptable
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 misrepresentation made in this document and its attachments shall cause the PHOTO
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: BIR

ID/License/Passport No.: 706-935-981

Signature (Sign inside the box)
09/20/2019
Date/Place of Issuance: 08/17/2017
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.
PMAJ JOSEPH F DEL CASTILLO
Person Administering Oath

CS FORM 212 (Revised 2017), Page 4 of 4