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 ag
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 CS

I. PERSONAL INFORMATION
2. SURNAME TEJADA
NAME EXTENSION (JR., SR)
FIRST NAME RANDOLF

MIDDLE NAME DELA CRUZ

3. DATE OF BIRTH
(mm/dd/yyyy) 04/16/1991 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by birth by naturaliz
4. PLACE OF BIRTH BANAYOYO, ILOCOS SUR If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS N/A N/A

Widowed Separated
House/Block/Lot No. Street
N/A POBLACION
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 1.57 BANAYOYO ILOCOS SUR
City/Municipality Province
8. WEIGHT (kg) 74 ZIP CODE 2708
18. PERMANENT ADDRESS N/A N/A
9. BLOOD TYPE O
House/Block/Lot No. Street
N/A POBLACION
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A BANAYOYO ILOCOS SUR

City/Municipality Province
12. PHILHEALTH NO. 05-201088984-7 ZIP CODE 2708
13. SSS NO. 34-4242195-6 19. TELEPHONE NO.

14. TIN NO. 421-586-487-000 20. MOBILE NO.

15. AGENCY EMPLOYEE NO. 2015-05 21. E-MAIL ADDRESS (if any)

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (m
NAME EXTENSION (JR., SR)
FIRST NAME N/A N/A 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 TEJADA

NAME EXTENSION (JR., SR)
FIRST NAME FELICITO JR.

MIDDLE NAME GALANGA

25. MOTHER'S MAIDEN NAME

 SURNAME DELA CRUZ

FIRST NAME MA LOURDES

MIDDLE NAME ABIGANA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE LEVEL/
26. PERIOD OF ATTENDANCE YEAR
UNITS
LEVEL (Write in full) EARNED
GRADUATED
(Write in full) (if not
From To
graduated)
ELEMENTARY BANAYOYO CENTRAL SCHOOL PRIMARY EDUCATION 1998 2004 N/A 2004

VOCATIONAL /
SECONDARY COMMONWEALTH HIGH SCHOOL HIGH SCHOOL 2004 2008 N/A 2008

AMA COMPUTER LEARNING

COMPUTER HARDWARE SERVICING 2008 2010 N/A 2010
CENTER

COLLEGE TRADE AMA COMPUTER UNIVERSITY COMPUTER ENGINEERING 2014 2015 86 N/A
COURSE

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

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017
e/criminal case/s against the

(Do not fill up. For CSC use only)

NSION (JR., SR)

enship

by naturalization
ndicate country:

N/A
Street
POBLACION
Barangay
ILOCOS SUR
Province

N/A
Street
POBLACION
Barangay
ILOCOS SUR
Province

DATE OF BIRTH (mm/dd/yyyy)

N/A
ecessary)

SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED

N/A

N/A

N/A

N/A

N/A

S 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

CAREER SERVICE EXAMINATION - PEN ST. LOUIS COLLEGE, LINGSAT, SAN

80.01% 10/14/2018
AND PAPER TEST (PROFESSIONAL LEVEL) FERNANDO CITY, LA UNION

(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
SERVICE
28. INCLUSIVE DATES SALARY/ JOB/
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY PAY GRADE (if STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To (Y/
N)
LOCAL GOVERNMENT UNIT -
1/3/2015 PRESENT CONTRACTUAL ENGINEERING AIDE 50000.00 N/A CONTRACTUAL N
BANAYOYO
LOCAL GOVERNMENT UNIT -
1/1/2011 12/31/2014 CONTRUCTUAL DATA ENCODER 6000.00 N/A CONTRACTUAL N
BANAYOYO
 (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
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (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
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) From To Technical/etc)

LOCAL ROAD MAPPING USING THE UNIFIED DEPARTMENT OF THE INTERIOR AND
MAPPING PROGRAM (UMP) OF NAMRIA 10/26/2018 10/26/2018 8.00 TECHNICAL LOCAL GOVERNMENT (PROVINCIAL
INCLUDING PROVINCIAL, CITY, MUNICIPAL OPERATIONS OFFICE)

DEPARTMENT OF TRANSPORTATION
LOCAL PUBLIC TRANSPORTATION ROUTE
LAND TRANSPORTATION FRANCHISING
PLANNING AND MANAGEMENT COURSE 1/10/2018 10/0152018 40.00 TECHNICAL
& REGULATORY BOARD (REGIONAL
(SESSION 2)
OFFICE)

DEPARTMENT OF THE INTERIOR AND

ROLL OUT OF THE SUBAYBAYAN TO FOCAL
09/19/2018 09/19/2018 8.00 TECHNICAL LOCAL GOVERNMENT (PROVINCIAL
PERSONS AND DILG-FIELD OFFICERS
OPERATIONS OFFICE)
DEPARTMENT OF TRANSPORTATION
LOCAL PUBLIC TRANSPORTATION ROUTE
LAND TRANSPORTATION FRANCHISING
PLANNING AND MANAGEMENT COURSE 10/9/2018 09/14/2018 32.00 TECHNICAL
& REGULATORY BOARD (REGIONAL
(SESSION 1)
OFFICE)
ROLL OUT TRAINING AND ORIENTATION OF
DEPARTMENT OF THE INTERIOR AND
THE GUIDELINES ON THE FUNCTIONALITY OF
8/9/2018 9/9/2018 16.00 TECHNICAL LOCAL GOVERNMENT (PROVINCIAL
LOCAL ADAC, IDMRIS, AND PERFORMANCE
OPERATIONS OFFICE)
AUDIT OF ADACS
DEPARTMENT OF THE INTERIOR AND
SEMINAR - WORKSHOP ON CONSTRUCTORS'
11/12/2017 12/15/2017 40.00 TECHNICAL LOCAL GOVERNMENT (PROVINCIAL
PERFORMANCE EVALUATION SYSTEM (CPES)
OPERATIONS OFFICE)

DEPARTMENT OF THE INTERIOR AND

TRAINING ON PROVINCIAL ROAD NETWORK
10/25/2017 10/27/2017 24.00 TECHNICAL LOCAL GOVERNMENT (PROVINCIAL
MAP DIGITIZING
OPERATIONS OFFICE)

CONSULTATION DIALOGUE WITH LGUs AND

DEPARTMENT OF THE INTERIOR AND
FIELD OFFICERS ON THE IMPLEMENTATION ON
02/15/2018 02/17/2017 24.00 TECHNICAL LOCAL GOVERNMENT (PROVINCIAL
LOCALLY-FUNDED PROJECTS CUM
OPERATIONS OFFICE)
GEOTAGGING ORIENTATION AND APPLICATION

DEPARTMENT OF THE INTERIOR AND

MODULE 6: TRAINING-WORKSHOP ON CLUP
10/22/2012 10/26/2012 40.00 TECHNICAL LOCAL GOVERNMENT (PROVINCIAL
IMPLEMENTATION TOOLS
OPERATIONS OFFICE)

MODULE 5: THE HANDS-ON DEPARTMENT OF THE INTERIOR AND

PREPARATION/UPDATING OF THE 07/30/2012 3/8/2012 40.00 TECHNICAL LOCAL GOVERNMENT (PROVINCIAL
COMPREHENSIVE LAND USE PLAN (PART II) OPERATIONS OFFICE)
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 33.
(Write in full) (Write
in full)
ENCODING N/A N/A

COMPUTER HARDWARE SERVICING

PROGRAMMING

GEO TAGGING

PHOT EDITING

(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? 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
YES ✘ NO
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, YES ✘ NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or If YES, give details:
phased 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 YES ✘ NO
(except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
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?
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
a.
items:
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
POBLACION, BANAYOYO, the last 6 months
ENGR. JOHN A. PRE ILOCOS SUR
09178196428 3.5 cm. X 4.5 cm
(passport size)
BISANGOL, BANAYOYO,
ZENAIDA B. SUBAGAN ILOCOS SUR
09157620243 With full and handwritten
name tag and signature over
BANBANAAL, BANAYOYO, printed name
MARK ANDREW G. CONCEPCION ILOCOS SUR
09955035976
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct or photocopied picture
is not acceptable
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 PHOTO
filing of 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: VOTER'S ID

ID/License/Passport No.: 2902-0002A-D1691RDT1000

Signature (Sign inside the box)

Date/Place of Issuance: BANAYOYO, ILOCOS SUR

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