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 CATLI
NAME EXTENSION (JR., SR)
FIRST NAME ARCIE

MIDDLE NAME IGAYA

3. DATE OF BIRTH
1/4/1998 16. CITIZENSHIP Dual
(mm/dd/yyyy) ✘ Filipino
Citizenship
by by
birth naturalization
4. PLACE OF BIRTH PJG CABANATUAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male
Female
6 CIVIL STATUS ✘ Single 17. RESIDENTIAL ADDRESS BLOCK 3 LOT 24
Married House/Block/Lot No. Street
Widowe Separat
MARKVILLE SUBDIVISION MAYAPYAP SUR
d ed
Other/s: Subdivision/Village Barangay
CABANATUAN NUEVA ECIJA
7. HEIGHT (m) 1.72
City/Municipality Province
8. WEIGHT (kg) 95 ZIP CODE 3100
18. PERMANENT ADDRESS BLOCK 3 LOT 24
9. BLOOD TYPE o
House/Block/Lot No. Street
MARKVILLE SUBDIVISION MAYAPYAP SUR
10. GSIS ID NO.
Subdivision/Village Barangay
CABANATUAN NUEVA ECIJA
11. PAG-IBIG ID NO.
City/Municipality Province

12. PHILHEALTH NO. ZIP CODE 3100

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 715-527-699 20. MOBILE NO. 09534961270

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

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME CATLI

NAME EXTENSION (JR., SR)
FIRST NAME ROMEO

MIDDLE NAME MARCOS

25. MOTHER'S MAIDEN NAME IGAYA

SURNAME CATLI

FIRST NAME IRENE

MIDDLE NAME DELA CRUZ (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 HOLY ANGELS ACADEMY 6/16/2004 03/27/2010 2010 NONE

SECONDARY LA FORTUNA COLLEGE 6/11/2011 5/23/2014 2014 NONE

VOCATIONAL /

NC III 3/7/2015 4/17/2015 2015 NONE

TRADE
COURSE GOVERNMENT
COLLEGE AUROLLO UNIVERSITY 05/16/2015 5/25/2019 2019 SCHOLAR

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE
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

(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)
1/4 YEAR
5/16/2019 9/23/2020 TEACHER I NEDA ACADEMY AND 4
MONTHS
3/25/2023 10/11/2023 DATA ENCODER I DEPARTMENT OF ENVIRONMENT AND 8
NATURAL RESOURCES MONTHS

(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 / NATURE OF WORK
From To

(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

(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)

COMPUTER LETERACY

EVENT MANAGEMENT
1.FINALS MVP INTRMURALS 2014 2. SEASON MVP INTERCLUB 2019, 2022,2023
BASKETBALL 3.LAKEWOOD BASKETBALL CLUB FINALS MVP 4. 3X3 CHAMPION MAYAPYAP
POCKET TOURNAMENT.

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 3 of 4
==== 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 ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘

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:
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
RIGIDOR M. DE LEON SAN ATONIO, SAN LEONARDO NUEVA the last 6 months
ECIJA 4.5 cm. X 3.5 cm
(passport size)
SONNY DE LEON LA TORRE TALAVERA NUEVA ECIJA
Computer generated
or photocopied picture
JOHN LEWIS FERRER MAYAPYAP SUR CABANATUAN CITY 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.:
Signature (Sign inside the box)

Date/Place of Issuance:
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