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 Lanuzga
NAME EXTENSION (JR., SR
FIRST NAME Jempol

MIDDLE NAME Villacorte

3. DATE OF BIRTH
(mm/dd/yyyy) 11/30/1998 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by

4. PLACE OF BIRTH La Opinion Nabua Camarines Sur If holder of dual citizenship, Pls. indicate cou

Female please indicate the details.

5. SEX ✘ Male

✘ Single Married 17. RESIDENTIAL ADDRESS 379 Zo

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. S
Other/s: N/A La O
Subdivision/Village Ba
7. HEIGHT (m) 1.73 m Nabua Camar
City/Municipality Pr
8. WEIGHT (kg) 54 kgs ZIP CODE 4434

9. BLOOD TYPE N/A

18. PERMANENT ADDRESS 379 Zo
House/Block/Lot No. S

10. GSIS ID NO. N/A N/A La O

Subdivision/Village Ba

11. PAG-IBIG ID NO. 121248317896 Nabua

City/Municipality Pr

12. PHILHEALTH NO. 102540267682 ZIP CODE 4434

13. SSS NO. 0515133598 19. TELEPHONE NO. N/A

14. TIN NO. 735006436 20. MOBILE NO. 09774820178

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) jempol1130@gmail.com
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 N/A N/A

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME Lanuzga (+)

NAME EXTENSION (JR., SR)
FIRST NAME Efren N/A
MIDDLE NAME Pacer

25. MOTHER'S MAIDEN NAME Gregoria Salles Villacorte

SURNAME Villacorte

FIRST NAME Gregoria

MIDDLE NAME Salles (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 La Opininion Elementary School N/A 6/6/2005 3/28/2011 N/A

SECONDARY Nabua National High School N/A 6/6/2011 ### N/A

VOCATIONAL /

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

TRADE
COURSE Bachelor of Science In Computer
COLLEGE Camarines Sur Polytechnic Colleges 6/8/2015 4/4/2019 N/A
Science

GRADUATE STUDIES N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 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:

Zone 3
Street
La Opinion
Barangay
Camarines Sur
Province
4434
Zone 3
Street
La Opinion
Barangay
Camarines Sur
Province

N/A

09774820178

jempol1130@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

N/A

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2011

2015
 N/A

2019

N/A

parate sheet if necessary)

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

Career Service Professional Eligibility 80.4 3/17/2019 Naga City 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. GOV'T
SERVICE
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 (Y/
N)
N/A N/A N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 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

Storehouse For All Nations Ministry 5/23/2012 Present N/A Ministry Youth Leader

Junior Philippine Computer Society- CSPC Chapter 6/8/2015 4/4/2019 N/A Member

Executive Committee 6/8/2015 4/4/2019 N/A Member

(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

Computer System Servicing NCII 1/7/2019 2/16/2019 N/A Technical TESDA

9th Bicol Youth Congress In Information Technology 12/6/2018 12/8/2018 3 days Technical Junior Philipp

8th Bicol Youth Congress In Information Technology 12/11/2016 1213/2016 3 days Technical Junior Philipp

7th Youth Congress In InformationTechnology 12/7/2016 12/9/2016 3 days Technical Junior Philipp

6th Bicol Youth Congress In Information Technology 12/10/2015 12/12/2015 3 days Technical Junior Philipp

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

Junior P

(Continue on separate sheet if necessary)

SIGNATURE DATE
EOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

Ministry Youth Leader

Member

Member

te sheet if necessary)

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

CONDUCTED/ SPONSORED BY
(Write in full)

TESDA

Junior Philippine Computer Society

Junior Philippine Computer Society

Junior Philippine Computer Society

Junior Philippine Computer Society

te sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION

(Write in full)
 Storehouse For All Nations Ministry

Junior Philippine Computer Society

Executive Committee

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,
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 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
Caroline S. Midel Naga City 3.5 cm. X 4.5 cm
(passport size)

Vinajoe Salvador Naga City With full and handwritten

name tag and signature over
printed name
Ptra. Cherry Saldo Nabua Camarines Sur
Computer generated
42. or photocopied picture
I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and 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)

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

 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