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 agai
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

I. PERSONAL INFORMATION
2. SURNAME BEDOYA
NAME EXTENSION (JR., SR)
FIRST NAME ALLYSA MAE

MIDDLE NAME RECTO

3. DATE OF BIRTH
(mm/dd/yyyy) MAY 14,1997 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by naturalizati
4. PLACE OF BIRTH CALAPAN CITY OR. MDO If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

✘ Single Married 17. RESIDENTIAL ADDRESS TIBANGLIN

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
DEL PILAR
Other/s:
Subdivision/Village Barangay
NAUJAN ORIENTAL MINDORO
7. HEIGHT (m) 1.56
City/Municipality Province
8. WEIGHT (kg) 52 ZIP CODE 5204
18. PERMANENT ADDRESS ZONE 7 WAWA
9. BLOOD TYPE AB+
House/Block/Lot No. Street
MALABAN
10. GSIS ID NO. N/A
Subdivision/Village Barangay
BIÑAN CITY LAGUNA
11. PAG-IBIG ID NO. 121227154498
City/Municipality Province
12. PHILHEALTH NO. 010263183415 ZIP CODE 4024
13. SSS NO. 3476459431 19. TELEPHONE NO.

14. TIN NO. N/A 20. MOBILE NO. 09356435889

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) bedoyaallysamae@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/d

FIRST NAME N/A N/A

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME BEDOYA

NAME EXTENSION (JR., SR)
FIRST NAME FRANCISCO

MIDDLE NAME RIVERA

25. MOTHER'S MAIDEN NAME

SURNAME RECTO

FIRST NAME ALICIA

MIDDLE NAME RAMIREZ (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)
FILEMON SAMACO MEMORIAL MARCH,
ELEMENTARY
SCHOOL
N/A JUNE,2004 2010 N/A 2010
VOCATIONAL / PEDRO V. PANALIGAN NATIONAL MARCH,
SECONDARY
HIGH SCHOOL
N/A JUNE,2010
2014
N/A 2014

N/A N/A

PAMANTASAN NG LUNGSOD NG BACHELOR OF SCIENCE IN JUNE,

COLLEGE TRADE JUNE, 2014 GRADUATE 2018
COURSE MUNTINLUPA CRIMINOLOGY 2018
GRADUATE STUDIES N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), P
e/s against the

For CSC use only)

turalization

ry:

DORO

RTH (mm/dd/yyyy)

N/A

SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED

N/A

N/A

N/A
ed 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
LICENSURE EXAMINATION FOR DECEMBER 14-16 05-14-
78.9 2018
MANILA 0180759 2022
CRIMINOLOGY
N/A N/A N/A N/A N/A N/A

(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)
MANILA TOLL EXPRESSWAY
06-19-2018 09-29-2018 MAINTENANCE CLERK 14000.00 RELIEVER NO
SERVICES (SLEX)
JOSEFINA VILLAMOR MANAGEMENT CONTRACT
02-26-2019 05-31-2019 MEDICAL ENCODER 6000.00 NO
CORPORATION (LTO) UAL
N/A 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), 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
MUNTINLUPA BUREAU OF FIRE AND
SEPT.2017 DEC.2017 270 HRS ON-THE-JOB-TRAINEE
PROTECTION
MUNTINLUPA POLICE STATION JAN.2018 APR.2018 270 HRS ON-THE-JOB-TRAINEE

N/A N/A N/A N/A 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)
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)

NAVAL RESERVE OFFICER TRANING CORPS

JUL.2014 MAR.2015 N/A N/A MAJ. FIDEL MACATANGAY
(NROTC)
DRIVING COURSE 10-14-2016 10-16-2016 5HRS N/A
MS. RUTH A CABA
FIRST AID AND BASIC LIFE SUPPORT 2/5/2017 2/5/2017 7HRS N/A
DR. INA RAGOTERO
WRITING CASE STUDY AND ANALYSIS REPORT 01-21-2018 01-21-2018 7HRS N/A
CESAR CALMADA MA.CRIM.
N/A N/A N/A N/A N/A N/A

(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)
PROFESSIONAL CRIMINOLOGIST
COMPUTER LITERATE N/A
ASSOCIATION OF THE PHILIPPINES
SING N/A

N/A

(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
STO.NIÑO, NEO CALAPAN the last 6 months
DR. ROMEO SALVADORA CITY, OR. MDO
9276188604 3.5 cm. X 4.5 cm
(passport size)

ETHEL B. COMO RCRIM. PANIKIAN, NAUJAN, OR MDO 90797777572 With full and handwritten
name tag and signature over
printed name
SPO2 ELMER LEYNES PUERTO GALERA, OR MDO 9566697588
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: PRC ID

ID/License/Passport No.: 0180759

Signature (Sign inside the box)

Date/Place of Issuance: 02-06-2019, MANILA

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