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 ag
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.

I. PERSONAL INFORMATION
2. SURNAME GARCIA
NAME EXTENSION (JR., SR
FIRST NAME JETHRO

MIDDLE NAME SORIANO

3. DATE OF BIRTH
(mm/dd/yyyy) 2/11/1996 16. CITIZENSHIP ✘ Filipino Dual Citizenship
✘ by birth by
4. PLACE OF BIRTH LOOC, ROMBLON If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX ✘ Male Female

✘ Single Married 17. RESIDENTIAL ADDRESS

6 CIVIL STATUS
Widowed Separated House/Block/Lot No.

Other/s:
Subdivision/Village B
LOOC R
7. HEIGHT (m) 1.77 m
City/Municipality
8. WEIGHT (kg) 76 kg ZIP CODE 5507
18. PERMANENT ADDRESS
9. BLOOD TYPE A
House/Block/Lot No.

10. GSIS ID NO. N/A

Subdivision/Village B
LOOC
11. PAG-IBIG ID NO. 121214540938
City/Municipality

12. PHILHEALTH NO. 09-000096417-3 ZIP CODE 5507

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

14. TIN NO. 712-324-767-000 20. MOBILE NO. 09065115231

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) jethrogarcia122@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) N/A
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 GARCIA

NAME EXTENSION (JR., SR)
FIRST NAME JERRY
 MIDDLE NAME GALICIA

25. MOTHER'S MAIDEN NAME

SURNAME SORIANO

FIRST NAME JURY

MIDDLE NAME FERNANDO (Continue on separate sheet if necessa

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY SACRED HEART SCHOOL PRIMARY 2003 2009 GRADUATED

SECONDARY /
VOCATIONAL LOOC NATIONAL HIGH SCHOOL SECONDARY 2009 2013 GRADUATED

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

TRADE
COURSE BACHELOR IN SECONDARY
COLLEGE ROMBLON STATE UNIVERSITY EDUCATION MAJOR IN 2013 2017 GRADUATED
MATHEMATICS

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

(Continue on separate sheet if necessary)

SIGNATURE DATE Janua

CS F
L DATA SHEET
rience Sheet shall cause the filing of administrative/criminal case/s against the person

FORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Dual Citizenship

by naturalization

Pls. indicate country:

Street
PUNTA
Barangay
ROMBLON
Province

Street
PUNTA
Barangay
ROMBLON
Province

N/A

09065115231

jethrogarcia122@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

N/A
 (Continue on separate sheet if necessary)

YEAR SCHOLARSHIP/
GRADUATED ACADEMIC HONORS
RECEIVED

2ND
2009
DESERVING

2013 VALEDICTORIAN

N/A N/A

WITH
2017 ACADEMIC
DISTINCTION

N/A N/A
parate sheet if necessary)

January 18, 2018

CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable)
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

Board Licensure Examination for Professional

84.80 9/24/2017 Colegio De San Juan De Letan
Teachers

(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.
SALARY/ JOB/
28. INCLUSIVE DATES PAY GRADE (if
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY applicable)&
(Write in full/Do not (Write in full/Do SALARY STEP (Format
abbreviate) not abbreviate) "00-0")/
From To INCREMENT

N/A
 (Continue on separate sheet if necessary)

SIGNATURE DATE January 18, 201

CS FORM 212 (R
 LICENSE (if applicable)

NUMBER Date of
Validity

1608653 11/2/2021

on separate sheet if necessary)

of duties should be indicated in the attached Work Experience sheet. GOV'T

SERVICE

STATUS OF
APPOINTMENT

(Y/
N)
on separate sheet if necessary)

January 18, 2018

CS FORM 212 (Revised 2017), Page 2 of 4
 VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
29. INCLUSIVE DATES

(mm/dd/yyyy) NUMBER OF HOURS POSITION / NAT

NAME & ADDRESS OF ORGANIZATION
(Write in full) From To

N/A

(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)

30. INCLUSIVE DATES OF

ATTENDANCE Type of LD
TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
( Managerial/ CONDUCTED/ SPO
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To

N/A
VIII
.
OT
HE
(Continue on separate sheet if necessary)
R
INF
OR NON-ACADEMIC DISTINCTIONS / RECOGNITION
MEMBERSHIP
MA31. SPECIAL SKILLS and HOBBIES 32.
(Write in full)
33.

TIO
N SINGING JOURNALISM AWARD ON "THE HARROW"

WRITING POEM BEST ACTOR IN THEATHER ARTS

FOLK DANCING Nothing Follows

Nothing Follows

(Continue on separate sheet if necessary)

SIGNATURE DATE January

 POSITION / NATURE OF WORK

PROGRAMS ATTENDED

CONDUCTED/ SPONSORED BY
(Write in full)
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in
full)

N/A

January 18, 2018

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
YES ✘ NO
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 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 YES ✘ NO
Barangay election)?
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
the last 6 months
REYNALDO R. LIBERATO LOOC, ROMBLON 9057666306 3.5 cm. X 4.5 cm
(passport size)

MARICHE S. GARACHICO LOOC, ROMBLON With full and handwritten

name tag and signature over
printed name
MARGARITA M. LLANDILAR STA. MARIA, ROMBLON 9174866706
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: POSTAL ID

ID/License/Passport No.: G64170332482 Signature (Sign inside the box)

01/18/2018
Date/Place of Issuance: 05-29-17/LOOC, ROMBLON
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.

SHERRYL LOU F. MIRABETE

Person Administering Oath

CS FORM 212 (Revised 2017), Page

If YES, give details (country):
, affiant exhibiting his/her validly issued government ID as indicated above.

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