Engr. Daneca Pds.xlsx
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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 agai 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 Fesarillo
2. SURNAME FIRST NAME
Daneca
MIDDLE NAME
Fernando
NAME EXTENSION (JR., SR)
3. DATE OF BIRTH (mm/dd/yyyy)
09/27/1993
4. PLACE OF BIRTH
Poblacion,Santa Fe,Romblon
5. SEX
Female
6 CIVIL STATUS
Married
16. CITIZENSHIP
Pls. indicate country:
If holder of dual citizenship, please indicate the details. 17. RESIDENTIAL ADDRESS
7. HEIGHT (m) 8. WEIGHT (kg)
House/Block/Lot No.
Street
Subdivision/Village
Barangay
City/Municipality
Province
House/Block/Lot No.
Street
Subdivision/Village
Barangay
City/Municipality
Province
ZIP CODE 18. PERMANENT ADDRESS
9. BLOOD TYPE 10. GSIS ID NO. 11. PAG-IBIG ID NO. 12. PHILHEALTH NO.
ZIP CODE
13. SSS NO.
19. TELEPHONE NO.
14. TIN NO.
20. MOBILE NO.
15. AGENCY EMPLOYEE NO.
21. E-MAIL ADDRESS (if any)
II. FAMILY BACKGROUND 22. SPOUSE'S SURNAME
Fesarillo
FIRST NAME
Jared
MIDDLE NAME
Foja
23. NAME of CHILDREN (Write full name and list all)
DATE OF BIRTH (mm/d
NAME EXTENSION (JR., SR)
OCCUPATION
Seaman
EMPLOYER/BUSINESS NAME
Montenegro Shipping Lines
BUSINESS ADDRESS TELEPHONE NO. 24. FATHER'S SURNAME NAME EXTENSION (JR., SR)
FIRST NAME MIDDLE NAME 25. MOTHER'S MAIDEN NAME SURNAME FIRST NAME
(Continue on separate sheet if necessary)
MIDDLE NAME
III. EDUCATIONAL BACKGROUND 26.
NAME OF SCHOOL
BASIC EDUCATION/DEGREE/COURSE (Write in full)
LEVEL (Write in full) ELEMENTARY VOCATIONAL / SECONDARY
COLLEGE TRADE COURSE
PERIOD OF ATTENDANCE
From
To
HIGHEST LEVEL/ YEAR UNITS GRADUATED EARNED (if not graduated)
GRADUATE STUDIES
(Continue on separate sheet if necessary)
SIGNATURE
DATE
CS FORM 212 (Revised 2017), P
e/s against the
For CSC use only)
ry:
RTH (mm/dd/yyyy)
SCHOLARSHIP/ ACADEMIC HONORS RECEIVED
ed 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY 27.
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEE BARANGAY ELIGIBILITY / DRIVER'S LICENSE
RATING (If Applicable)
DATE OF EXAMINATION / CONFERMENT
LICENSE (if applicab PLACE OF EXAMINATION / CONFERMENT
Civil Engineering Board Examination
NUMBER
140715
(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 (mm/dd/yyyy) From
To
POSITION TITLE
DEPARTMENT / AGENCY / OFFICE / COMPANY (Write in full/Do not abbreviate)
Office Engineer Engineer 1
(Write in full/Do not abbreviate)
ASEC Development & Construction Corporation Local Goverment Unit (Santa Fe)- Office of the Municipal Engineer
(Continue on separate sheet if necessary)
SIGNATURE
DATE
MONTHLY SALARY
SALARY/ JOB/ PAY GRADE (if applicable)& STEP (Format "00-0")/ INCREMENT
STATUS OF APPOINTMENT
21000.00
ProjectBased
13000.00
JO
CS FORM 212 (Revised 2017), Pa
LICENSE (if applicable) Date of Validity
n separate sheet if necessary)
n separate sheet if necessary)
GOV'T SERVICE
(Y/ N)
N Y
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 29.
(Write in
INCLUSIVE DATES
full) From
(mm/dd/yyyy) To
POSITION / NATURE OF WORK
NUMBER OF HOURS
(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 Type of LD ATTENDANCE TITLE OF LEARNING AND DEVELOPMENT 30. CONDUCTED/ SPONSORED BY ( Managerial/ NUMBER OF HOURS INTERVENTIONS/TRAINING PROGRAMS Supervisory/ (Write in full) (mm/dd/yyyy) (Write in full) Technical/etc) From To
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION 31.
SPECIAL SKILLS and HOBBIES
NON-ACADEMIC DISTINCTIONS / RECOGNITION (Write in full)
33.
MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full)
(Continue on separate sheet if necessary)
SIGNATURE
DATE 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? b. within the fourth degree (for Local Government Unit - Career Employees)? If YES, give details: ________________________________
35.
a. Have you ever been found guilty of any administrative offense? If YES, give details: ________________________________ ________________________________ b. Have you been criminally charged before any court? If YES, give details: ________________________________ Date Filed: ________________________________ Status of Case/s:
36.
37.
38.
Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal?
Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in the public or private sector? a. Have you ever been a candidate in a national or local election held within the last year (except Barangay election)?
If YES, give details: ________________________________ ________________________________ If YES, give details: ________________________________ ________________________________ If YES, give 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? 39.
If YES, give details:
Have you acquired the status of an immigrant or permanent resident of another country? If YES, give details (country):
40.
a.
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: 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 3.5 cm. X 4.5 cm (passport size) With full and handwritten name tag and signature over printed name Computer generated or photocopied picture is not acceptable
42.
I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct 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 filing of administrative/criminal case/s against me.
PHOTO
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.: Date/Place of Issuance:
SUBSCRIBED AND SWORN to before me this
Signature (Sign inside the box) Date Accomplished
Right Thumbmark
, affiant exhibiting his/her validly issued government ID as indicated above.
Person Administering Oath
CS FORM 212 (Revised 2017), Page 4 of 4
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 agai 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 Fesarillo
2. SURNAME FIRST NAME
Daneca
MIDDLE NAME
Fernando
NAME EXTENSION (JR., SR)
3. DATE OF BIRTH (mm/dd/yyyy)
09/27/1993
4. PLACE OF BIRTH
Poblacion,Santa Fe,Romblon
5. SEX
Female
6 CIVIL STATUS
Married
16. CITIZENSHIP
Pls. indicate country:
If holder of dual citizenship, please indicate the details. 17. RESIDENTIAL ADDRESS
7. HEIGHT (m) 8. WEIGHT (kg)
House/Block/Lot No.
Street
Subdivision/Village
Barangay
City/Municipality
Province
House/Block/Lot No.
Street
Subdivision/Village
Barangay
City/Municipality
Province
ZIP CODE 18. PERMANENT ADDRESS
9. BLOOD TYPE 10. GSIS ID NO. 11. PAG-IBIG ID NO. 12. PHILHEALTH NO.
ZIP CODE
13. SSS NO.
19. TELEPHONE NO.
14. TIN NO.
20. MOBILE NO.
15. AGENCY EMPLOYEE NO.
21. E-MAIL ADDRESS (if any)
II. FAMILY BACKGROUND 22. SPOUSE'S SURNAME
Fesarillo
FIRST NAME
Jared
MIDDLE NAME
Foja
23. NAME of CHILDREN (Write full name and list all)
DATE OF BIRTH (mm/d
NAME EXTENSION (JR., SR)
OCCUPATION
Seaman
EMPLOYER/BUSINESS NAME
Montenegro Shipping Lines
BUSINESS ADDRESS TELEPHONE NO. 24. FATHER'S SURNAME NAME EXTENSION (JR., SR)
FIRST NAME MIDDLE NAME 25. MOTHER'S MAIDEN NAME SURNAME FIRST NAME
(Continue on separate sheet if necessary)
MIDDLE NAME
III. EDUCATIONAL BACKGROUND 26.
NAME OF SCHOOL
BASIC EDUCATION/DEGREE/COURSE (Write in full)
LEVEL (Write in full) ELEMENTARY VOCATIONAL / SECONDARY
COLLEGE TRADE COURSE
PERIOD OF ATTENDANCE
From
To
HIGHEST LEVEL/ YEAR UNITS GRADUATED EARNED (if not graduated)
GRADUATE STUDIES
(Continue on separate sheet if necessary)
SIGNATURE
DATE
CS FORM 212 (Revised 2017), P
e/s against the
For CSC use only)
ry:
RTH (mm/dd/yyyy)
SCHOLARSHIP/ ACADEMIC HONORS RECEIVED
ed 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY 27.
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEE BARANGAY ELIGIBILITY / DRIVER'S LICENSE
RATING (If Applicable)
DATE OF EXAMINATION / CONFERMENT
LICENSE (if applicab PLACE OF EXAMINATION / CONFERMENT
Civil Engineering Board Examination
NUMBER
140715
(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 (mm/dd/yyyy) From
To
POSITION TITLE
DEPARTMENT / AGENCY / OFFICE / COMPANY (Write in full/Do not abbreviate)
Office Engineer Engineer 1
(Write in full/Do not abbreviate)
ASEC Development & Construction Corporation Local Goverment Unit (Santa Fe)- Office of the Municipal Engineer
(Continue on separate sheet if necessary)
SIGNATURE
DATE
MONTHLY SALARY
SALARY/ JOB/ PAY GRADE (if applicable)& STEP (Format "00-0")/ INCREMENT
STATUS OF APPOINTMENT
21000.00
ProjectBased
13000.00
JO
CS FORM 212 (Revised 2017), Pa
LICENSE (if applicable) Date of Validity
n separate sheet if necessary)
n separate sheet if necessary)
GOV'T SERVICE
(Y/ N)
N Y
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 29.
(Write in
INCLUSIVE DATES
full) From
(mm/dd/yyyy) To
POSITION / NATURE OF WORK
NUMBER OF HOURS
(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 Type of LD ATTENDANCE TITLE OF LEARNING AND DEVELOPMENT 30. CONDUCTED/ SPONSORED BY ( Managerial/ NUMBER OF HOURS INTERVENTIONS/TRAINING PROGRAMS Supervisory/ (Write in full) (mm/dd/yyyy) (Write in full) Technical/etc) From To
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION 31.
SPECIAL SKILLS and HOBBIES
NON-ACADEMIC DISTINCTIONS / RECOGNITION (Write in full)
33.
MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full)
(Continue on separate sheet if necessary)
SIGNATURE
DATE 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? b. within the fourth degree (for Local Government Unit - Career Employees)? If YES, give details: ________________________________
35.
a. Have you ever been found guilty of any administrative offense? If YES, give details: ________________________________ ________________________________ b. Have you been criminally charged before any court? If YES, give details: ________________________________ Date Filed: ________________________________ Status of Case/s:
36.
37.
38.
Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal?
Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in the public or private sector? a. Have you ever been a candidate in a national or local election held within the last year (except Barangay election)?
If YES, give details: ________________________________ ________________________________ If YES, give details: ________________________________ ________________________________ If YES, give 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? 39.
If YES, give details:
Have you acquired the status of an immigrant or permanent resident of another country? If YES, give details (country):
40.
a.
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: 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 3.5 cm. X 4.5 cm (passport size) With full and handwritten name tag and signature over printed name Computer generated or photocopied picture is not acceptable
42.
I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct 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 filing of administrative/criminal case/s against me.
PHOTO
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.: Date/Place of Issuance:
SUBSCRIBED AND SWORN to before me this
Signature (Sign inside the box) Date Accomplished
Right Thumbmark
, affiant exhibiting his/her validly issued government ID as indicated above.
Person Administering Oath
CS FORM 212 (Revised 2017), Page 4 of 4
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