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 ORBILLA
NAME EXTENSION (JR., SR)
FIRST NAME PERMARIE

MIDDLE NAME MENDEZ

3. DATE OF BIRTH
(mm/dd/yyyy) 09/21/2001 16. CITIZENSHIP
✘

4. PLACE OF BIRTH JIMENEZ, MISAMIS OCCIDENTAL If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘

17. RESIDENTIAL ADDRESS

6 CIVIL STATUS ✘
House/Block/Lot No. Street
PUROK 7 MACABAYAO
Subdivision/Village Barangay
7. HEIGHT (m) 5'O JIMENEZ MISAMIS OCCIDENTAL
City/Municipality Province
8. WEIGHT (kg) 47 ZIP CODE 7204
18. PERMANENT ADDRESS
9. BLOOD TYPE A+
House/Block/Lot No. Street
10. GSIS ID NO. N/A PUROK 7 MACABAYAO
Subdivision/Village Barangay
JIMENEZ MISAMIS OCCIDENTAL
11. PAG-IBIG ID NO. N/A
City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 7204

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

14. TIN NO. N/A 20. MOBILE NO. 09513034884

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME CABUG 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) AIRA MARIE O. LEOPOLDO
FIRST NAME PERLITA 8/10/2021

MIDDLE NAME MENDEZ

OCCUPATION HOUSEWIFE

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. 09126413481

24. FATHER'S SURNAME DECEASED

NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

25. MOTHER'S MAIDEN NAME CABUG

SURNAME ORBILLA

FIRST NAME PERLITA

MIDDLE NAME MENDEZ (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

BASIC EDUCATION
ELEMENTARY ESTRELLA ELEMENTARY SCHOOL 4/6/2013 03/28/2014 2014

BASIC EDUCATION
SECONDARY
VOCATIONAL / SINONOC NATIONAL HIGH SCHOOL 6/6/2018 05/21/2018 2018

(ICT) INFORMATION COMMUNICATION AND

SINONOC NATIONAL HIGH SCHOOL
TECHNOLOGY
6/6/2018 5/1/2120 2020
TRADE
COURSE UNIVERSITY OF SCIENCE AND TECHNOLOGY OF BACHELOR OF TECHNOLOGY AND LIVELIHOOD
COLLEGE
SOUTHERN PHILIPPINES - PANAON CAMPUS EDUCATION MAJOR IN HOME ECONOMICS
8/24/2020

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE February 9, 2024

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

(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
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)
PUBLIC /
07/20/2021 09/20/2021 WAITER / CLEANER ALEXA'S RESTAURANT 2500.00
2020
PUBLIC /
10/6/2021 07/15/2021 SALES LADY DEZEE'S DRY GOODS 4000.00
2020
 (Continue on separate sheet if necessary)

SIGNATURE DATE 02/09/24

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

(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

CAMPUS - WIDE STUDENT RESEARCH COLLOQUIUM 8/17/2023 8/17/2023 8 HOURS FACULTY OF USTP PANAON

FIELD STUDY ORIENTATION 08/20/2023 08/20/2023 5 HOURS

USTP PANAON FUNCTION HALL

PRACTICE TEACHING ORIENTATION 1/2/2024 1/2/2024 5 HOURS

USTP PANAON FUNCTION HALL

(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 in
(Write in full)
full)

COOKING
 DANCING

PLAYING

(Continue on separate sheet if necessary)

SIGNATURE DATE 02/09/24

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? ✘

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. Have you ever been convicted of any crime or violation of any law, decree, ordinance or 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, ✘
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 ✘
Barangay election)?
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? If YES, give details:
39. Have you acquired the status of an immigrant or permanent resident of another country?
✘

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? ✘
If YES, please specify: SUBANEN GROUP
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
WINSTON JOHN L. ROSAL MACABAYAO, JIMENEZ MIS.OCC 09381159470 3.5 cm. X 4.5 cm
(passport size)

JECOR GRACE R. PUNGYAN MACABAYAO, JIMENEZ MIS.OCC 09073089132 With full and handwritten
name tag and signature over
printed name
RUFINO LAGAAC MACABAYAO, JIMENEZ MIS.OCC 09610965403
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: N/A
ID/License/Passport No.: N/A Signature (Sign inside the box)
02/09/24
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 4