CS FORM 212 (Revised 2005)

Unique Applicant Number

PERSONAL DATA SHEET T15227074

1. CS ID
Print legibly. Mark appropriate boxes with " " and use separate sheet if necessary. No. (to be filled up by CSC)

I. PERSONAL INFORMATION
2. SURNAME LOZANO
FIRST NAME JEFREY
MIDDLE NAME VILLAFRANCA 3. NAME EXTENSION (e.g. Jr., Sr.)

16. RESIDENTIAL ADDRESS , CITY OF KIDAPAWAN (Capital), NORTH COTABATO

4. DATE OF BIRTH (mm/dd/yyyy) 02 / 22 / 1992
5. PLACE OF BIRTH

6. SEX MALE FEMALE

7. CIVIL STATUS
Single Widowed ZIP CODE 9400
Married Separated
17. TELEPHONE NO.
Annuled Others, specify
_________ 18. PERMANENT ADDRESS Kalaisan, CITY OF KIDAPAWAN (Capital), NORTH
COTABATO
8. CITIZENDSHIP Filipino
9. HEIGHT (m) 2
10. WEIGHT (kg) 58 ZIP CODE 9400
11. BLOOD TYPE A+ 19. TELEPHONE NO.

12. GSIS ID NO. 20. EMAIL ADDRESS (if any) jetruh22@gmail.com

13. PAGIBIG ID NO. 21. CELLPHONE NO. (if any) 09076442277
14. PHILHEALTH NO. 22. AGENCY EMPLOYEE NO.

15. SSS NO. 23. TIN

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUS. NAME

BUSINESS ADDRESS

TELEPHONE NO.

(Continue on separate sheet if necessary)

26. FATHER'S SURNAME Lozano

FIRST NAME Roland

MIDDLE NAME Rubio

27. MOTHER'S MAIDEN NAME

MOTHER'S SURNAME Villafranca

FIRST NAME Letecia

MIDDLE NAME Villegas

III. EDUCATIONAL BACKGROUND

HIGHEST
GRADE/ INCLUSIVE DATES OF
YEAR ATTENDANCE
LEVEL NAME OF SCHOOL DEGREE COURSE LEVEL/ UNITS SCHOLARSHIP/ ACADEMIC
GRADUATED
(Write in full) (Write in full) EARNED HONORS RECEIVED
(if graduated)
(if not
graduated) From To

ELEMENTARY Kalaisan Elementary School 2006 2000 2006 Valedictorian

SECONDARY Kalaisan National High School 2010 2006 2010 Valedictorian

VOCATIONAL/ TRADE
COURSE

University of Southern
Bachelor of
COLLEGE Mindanao-Kidapawan City 2016 2012 2016 Provincial Scholar
Secondary Education
Campus

GRADUATE STUDIES

IV. CIVIL SERVICE ELIGIBILITY

LOZANO, JEFREY VILLAFRANCA - T15227074 CS FORM 212 (Revised 2005), Page 1 of 3
29. LICENSE (if applicable)
DATE OF
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
UNDER SPECIAL LAWS/ CES/ CSEE DATE OF
CONFERMENT NUMBER
RELEASE
CES ELIGIBLE (CAREER EXECUTIVE SERVICE
ELIGIBILITY)

V. WORK EXPERIENCE
30. INCLUSIVE DATES SALARY
(mm/dd/yyyy) GRADE &
DEPARTMENT / AGENCY / OFFICE / MONTHLY STATUS OF GOV'T SERVICE
POSITION TITLE (Write in full) STEP
COMPANY (Write in full) SALARY APPOINTMENT (Yes / No)
INCREMENT
From To
(Format "00-0")

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

31. INCLUSIVE DATES
NAME & ADDRESS OF ORGANIZATION (mm/dd/yyyy) NUMBER OF
POSITION / NATURE OF WORK
(Write in full) HOURS
From To

Parish Youth Ministry-Kidapawan 03 / 05 / 2017 03 / 05 / 2017 P.R.O

VII. TRAINING PROGRAMS (Start from the most recent training.)

32. INCLUSIVE DATES OF
ATTENDANCE
TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES NUMBER OF CONDUCTED/ SPONSORED BY
(mm/dd/yyyy)
(Write in full) HOURS (Write in full)
From To

Kidapawan Young Leaders Congress 03 / 21 / 2016 03 / 23 / 2016 24

Seminar on the Pre-service Training and MOA Signing 10 / 28 / 2015 8

Cotabato Young Leaders Congress 10 / 28 / 2015 10 / 30 / 2015 24

Seminar on Current Methods and Statistical Analysis 07 / 30 / 2015 8 USM-KCC

VIII. OTHER INFORMATION

33. 34. NON-ACADEMIC DISTINCTIONS / RECOGNITION: 35. MEMBERSHIP IN ASSOCIATION / ORGANIZATION
SPECIAL SKILLS / HOBBIES:
(Write in full) (Write in full)

Carpentry Playing Chess Playing Table Tennis Parish Youth Council Kidapawan Young Leaders
and Basketball Cotabto Young Leaders

LOZANO, JEFREY VILLAFRANCA - T15227074 CS FORM 212 (Revised 2005), Page 2 of 3

36. Are you related by consanguinity or affinity to any of the following :

a. Within the third degree (for National Government Employees): YES NO

appointing authority, recommending authority, chief of office/bureau/department or person who
has immediate supervision over you in the Office, Bureau or Department where you will be If YES, give details:
appointed? _____________________________________
_____________________________________
_____________________________________

b. Within the fourth degree (for Local Government Employees): YES NO

appointing authority or recommending authority where you will be appointed?
If YES, give details:
_____________________________________
_____________________________________
_____________________________________

37. a. Have you ever been formally charged? YES NO

If YES, give details:
_____________________________________
_____________________________________

b. Have you ever been guilty of any administrative offense? YES NO

If YES, give details:
_____________________________________
_____________________________________

38. Have you ever been convicted of any crime or violation of any law, decree, ordinance or YES NO
regulation by any court or tribunal?
If YES, give details:
_____________________________________
_____________________________________

39. 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, AWOL
or phased out, in the public or private sector? If YES, give details:
_____________________________________
_____________________________________

40. Have you ever been a candidate in a national or local election (except Barangay election)? YES NO
If YES, give details:
_____________________________________
_____________________________________

41. 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 differently abled? YES NO
If YES, please specify:_______________________
c. Are you a solo parent? YES NO
If YES, please specify:_______________________

42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)

NAME ADDRESS TEL. NO.

Anthony Tongan Kidapawan City 09123776174

Antonio Pasigado Kidapawan City 09182841937

43. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and complete
statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. X
I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust that
this information shall remain confidential. PHOTO

194122

COMMUNITY TAX CERTIFICATE NO.

Kidapawan

ISSUED AT SIGNATURE (Sign inside the box)

2017-02-06 02 / 20 / 2017

ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

LOZANO, JEFREY VILLAFRANCA - T15227074 CS FORM 212 (Revised 2005), Page 3 of 3