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 against 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 use only)
I. PERSONAL INFORMATION
2. SURNAME PADIAG
NAME EXTENSION (JR., SR) N/A
FIRST NAME LOVELY

MIDDLE NAME PEREZ

3. DATE OF BIRTH
(mm/dd/yyyy) 5/5/2002 16. CITIZENSHIP
✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH PANAGANGAN LA PAZ AGUSAN DEL SUR If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX
Male ✘ Female
17. RESIDENTIAL ADDRESS PUROK 5
6 CIVIL STATUS Single
✘ Married House/Block/Lot No. Street
Widowed Separate PANAGANGAN
Other/s: d Subdivision/Village Barangay
LA PAZ AGUSAN DEL SUR
7. HEIGHT (m) 5'0
City/Municipality Province
8. WEIGHT (kg) 50kg ZIP CODE 8508

18. PERMANENT ADDRESS PUROK 5

9. BLOOD TYPE B+
House/Block/Lot No. Street
PANAGANGAN
10. GSIS ID NO. N/A
Subdivision/Village Barangay
LA PAZ AGUSAN DEL SUR
11. PAG-IBIG ID NO. 121343930605
City/Municipality Province

12. PHILHEALTH NO. 160259624220 ZIP CODE 8508

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

14. TIN NO. N/A 20. MOBILE NO. 09462971478

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) lovelypadiag8@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME 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 PADIAG

NAME EXTENSION (JR., SR)
FIRST NAME LARRY

MIDDLE NAME CERVANTES

25. MOTHER'S MAIDEN NAME

SURNAME PEREZ

FIRST NAME LILIA

MIDDLE NAME OTACAN (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST LEVEL/ SCHOLARSHIP/
26. NAME OF SCHOOL PERIOD OF ATTENDANCE YEAR
LEVEL (Write in BASIC EDUCATION/DEGREE/COURSE
(Write in full)
UNITS
GRADUATED
ACADEMIC
HONORS
full) EARNED
(if not graduated) RECEIVED
From To

ELEMENTARY DONA ADELA ELEMENTARY SCHOOL ELEMENTARY GRADUATE 2009 2015 GRADUATED 2015 N/A

PANAGANGAN NATIONAL HIGH SCHOOL & SECONDARY GRADUATE & SENIOR HIGH
SECONDARY INFORMATIC COMPUTER INSTITUTE GRADUATE 2015 2021 GRADUATED 2021 WITH HONORS
VOCATIONAL /

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

TRADE
COURSE DOH SCHOLAR &
COLLEGE TECARRO COLLEGE FOUNDATION INC. DIPLOMA IN MIDWIFERY 2021 2023 GRADUATED 2023 DISTINCTIVE
AWARDS

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

(Continue on separate sheet if necessary)

SIGNATURE DATE JULY 08, 2024

CS FORM 212 (Revised 2017), Page 1 of 4

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

MIDWIFERY LICENSURE EXAMINATION 82.8 APRIL 29-30, 2024 DAVAO CITY 0187710 5/5/2027

(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
28. INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY GRADE (if STATUS OF
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
abbreviate) full/Do not abbreviate) (Format "00-0")/
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 JULY 08, 2024

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

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

(Continue on separate sheet if necessary)

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

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

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

N/A N/A INTEGRATED MIDWIVES ASSOCIATION OF

THE PHILIPPINES (IMAP)

(Continue on separate sheet if necessary)

SIGNATURE DATE JULY 08, 2024

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
by any court or tribunal? YES ✘ NO
If YES, give details:
________________________________
________________________________
37. 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 YES ✘ NO
out (abolition) in the public or private sector? If YES, give details:
________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? YES ✘ NO
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: MANOBO
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
JAYVAN P. HELARION PUROK 1 COMOTA LA PAZ AGUSAN DEL the last 6 months
SUR 9467000493 4.5 cm. X 3.5 cm
(passport size)

JANE ALLEN D. BACLERAN POBLACION LA PAZ AGUSAN DEL SUR 9500001899

Computer generated
or photocopied picture
QUEENLOISE R. DE VENANCIO POBLACION LA PAZ AGUSAN DEL SUR 9950511295 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: PROFESSIONAL IDENTIFICATION CARD

ID/License/Passport No.: 0187710

Signature (Sign inside the box)
JULY 08, 2024
Date/Place of Issuance: 06/18/2024
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 4