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 ANNIBAN

FIRST NAME EDEN MARIE

MIDDLE NAME DUGAO

3. DATE OF BIRTH 07/11/1985 16. CITIZENSHIP

4. PLACE OF BIRTH PASWAY BALBALAN, KALINGA

5. SEX Female

6. CIVIL STATUS Single 17. RESIDENTIAL ADDRESS

BULANAO, TABUK CITY

7. HEIGHT (m) 151

8. WEIGHT (kg) 49

9. BLOOD TYPE B 18. PERMANENT ADDRESS

10. GSIS ID NO. 2004891469

11. PAG-IBIG ID NO. 121207222105

12. PHILHEALTH NO. 030002756311

13. SSS NO. 19. TELEPHONE NO.

14. PAG-IBIG ID NO. 20. MOBILE NO. 09392910007

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS(if any) anniban.e@yahoo.com

II. FAMILY BACKGROUND

23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
22. SPOUSE'S SURNAME
, DEXIE ASHLEY A. TAWACNIG 09/05/2006
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS
NAME

BUSINESS ADDRESS

TELEPHONE

24. FATHER'S SURNAME

FIRST NAME

MIDDLE NAME

25. MOTHER'S MAIDEN

NAME
SURNAME

FIRST NAME

MIDDLE NAME

III. EDUCATIONAL BACKGROUND

LEVEL NAME OF SCHOOL BASIC EDUCATION DEGREE/COURSE PERIOD OF ATTENDANCE HIGHEST LEVEL/ YEAR SCHOLARSHIP/
(Write in full) (Write in full) UNITS EARNED GRADUATED ACADEMIC
(If not graduated) HONORS
RECEIVED

COLLEGE SAINT LOUIS COLLEGE OF BS CRIMINOLOGY

BULANAO

(Continue on separate sheet if necessary)

SINATURE DATE
IV. CIVIL SERVICE ELIGIBILITY
CAREER SERVICE/ RA 1080(BOARD/BAR) UNDER RATING DATE OF LICENSE(If applicable)
SPECIAL LAWS/CES/CSEE (If Applicable) EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY/ DRIVER'S LICENSE CONFERMENT NUMBER VALIDITY

BOARD 6506 / BOARD PASSER RA 6506 (CRIM) 75.00% 04/03/2013 BAGUIO NATIONAL HIGH SCHOOL

V. WORK EXPERIENCE
(Include private employment.Start from your recent) Description of duties should be indicated in the attached Work Experience Sheet.

INCLUSIVE DATES Position Title DEPARTMENT/AGENCY/OFFICE/COM MONTHLY SALARY STATUS OF GOV'T

(mm/dd/yyyy) PANY SALARY GRADE APPOINTMENT SERVICE
& STEP
FROM TO INCREMENT

11/06/2014 03/14/2019 Police Officer I PHILIPPINE NATIONAL POLICE 14834 TEMPORARY

03/15/2019 Police Corporal PHILIPPINE NATIONAL POLICE 30867 PERMANENT

(Continue on separate sheet if necessary)

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

NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES NUMBER OF CONDUCTED/SPONSORED BY

HOURS
FROM TO

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 of Division Chief/Executive/ Managerial positions)

INCLUSIVE DATES Type of I.D CONDUCTED/

TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING OF ATTENDANCES NUMBER OF (Managerial/ SPONSORED BY
PROGRAMS (mm/dd/yyyy) HOURS Supervisor/ (Write in Full)
(Write in full) Technical/etc
FROM TO

PS FIELD TRAINING PROGRAM (POLICE OFFICER 1) 11/27/2014 12/15/2015 RTS1

VIII. OTHER INFORMATION

SPECIAL SKILLS/HOBBIES NON - ACADEMIC DISTINCTION / RECOGNITION MEMBERSHIP

ASSOCIATION/ORGANIZATION

1 Letter of Commendation

3 Medalya ng Kagalingan

3 Medalya ng Kasanayan

7 Medalya ng Kasanayan

2 Medalya ng Paglilingkod Laban sa Kriminalidad

1 Medalya ng Papuri

7 Medalya ng Papuri

1 Tsapa sa Natatanging Yunit

SINATURE DATE
 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, YES NO
Bureau or Department where you will be apppointed,
YES NO
a. within the third degree?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If Yes, give details:

YES NO
a. Have you ever been found guilty of any administrative offense?
If Yes, give details:

b. Have you ever been criminally changed before any court?

YES NO

If Yes, give details:

Date Filed:

Status of Case/s:

Have you ever been convicted of any crime or validation of any law, decree, ordinance or requlation by any court YES NO
or tribunal?
If Yes, give details:

Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped YES NO
from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in the public or
private sector? If Yes, give details:

a. Have you ever been a candidate in a national or local election held within the last year (except Barangay YES NO
election)?
If Yes, give details:

b. Have you resigned from the government service during the three (3)-month period before the last election to
promote/actively campaign for a national or local candidate? YES NO

If Yes, give details:

Have you acquired the status of an immigrant or permanent resident of another country? YES NO

If Yes, give details:

Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA 7277); and (c) Solo YES NO
Parents Welfare Act of 2000 (RA 8972), please answer the following items:
If Yes, give details:

a. Are you a member of any indigenous group? YES NO

If Yes, give details:
b. Are you a person with disability?
YES NO
c. Are you a solo parent? If Yes, give details:

ID picture taken within

the last 6 months
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten

name tag and signature over
printed name

Computer generated or
photocopied picture is not
I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete statement pursuant to the acceptable
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.

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License,

etc.)

PLEASE INDICATE ID Number and Date of Issuance

Government Issued ID:

Signature (Sign inside the box)

ID/License/Passport No.:

Rigth Thumbmark
Date/Place of Issuance: Date Accomplished

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

Person Administering Oath