CS Form No.

212

PERSONAL DATA SHEET

Revised 2017

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 RICO
NAME EXTENSION (JR., SR)
FIRST NAME ELYZAR
MIDDLE NAME RAMOS
3. DATE OF BIRTH
(mm/dd/yyyy) 8/5/1988 16. CITIZENSHIP
✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH RIZAL,DIFFUN,QUIRINO If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

Single Married 17. RESIDENTIAL ADDRESS L. Jaena

6 CIVIL STATUS ✘
House/Block/Lot No. Street
Widowed Separated
PUROK#5 RIZAL
Other/s: Subdivision/Village Barangay
DIFFUN QUIRINO
7. HEIGHT (m) 1.56M
City/Municipality Province
8. WEIGHT (kg) 65KG ZIP CODE 3401

18. PERMANENT ADDRESS L. Jaena

9. BLOOD TYPE TYPE O
House/Block/Lot No. Street
PUROK#5 RIZAL
10. GSIS ID NO. N/A
Subdivision/Village Barangay
DIFFUN QUIRINO
11. PAG-IBIG ID NO. N/A
City/Municipality Province
12. PHILHEALTH NO. N/A ZIP CODE 3401

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

14. TIN NO. 711-513-296-000 20. MOBILE NO. 09161587340
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) elyzarrico2@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME ACENAS 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) ZYRELLE MAE A. RICO
FIRST NAME BABY JANE 12/29/2010

MIDDLE NAME PINERA ELIJAH QUINN A. RICO 12/7/2017

OCCUPATION Casual
EMPLOYER/BUSINESS NAME Office of Vice Governor
BUSINESS ADDRESS Capitol hills, Cabarroguis, Quirino
TELEPHONE NO. N/A
24. FATHER'S SURNAME RICO
JR.
FIRST NAME CESAR
MIDDLE NAME DAR
25. MOTHER'S MAIDEN NAME

SURNAME RAMOS
FIRST NAME ELIZABETH
MIDDLE NAME RIGOR (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY DIFFUN CENTRAL SCHOOL Elementary 1995 2001 Graduated 2001 None
VOCATIONAL
SECONDARY / DIFFUN CENTRAL SCHOOL High School 2001 2005 Graduated 2005 None

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

TRADE
COLLEGE
COURSE QUIRINO STATE UNIVERSITY Banchelor of Science in Civil Engineering 2006 2016 Graduated 2016 None

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

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 6, 2020

CS FORM 212 (Revised 2017), Page 1 of 4

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

Professional Driver's Licencse N/A 01/24/2019 Cabarroguis Quirino B07-19-000252 5/8/2023

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE
GOV'T SERVICE
28. INCLUSIVE DATES SALARY/ JOB/ PAY
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY 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)

11/02/17 Present Non teaching Personel Quirinino State University 12,000 N/A COS N

07/18/17 9/26/2017 SKILLED WORKER Engr.Jovany Flores 9,120 N/A N/A N

11/10/11 02/10/12 PROMO ENDORSER DNF Globe telecom 8,000 N/A Job order N

08/16/10 03/17/11 SKILLED WORKER Engr.Edelmumdo Castaneda 8,000 N/A N/A N

03/15/01 05/28/02 LABORER Engr. Edelmundo Castaneda 7,200 N/A N/A N

 (Continue on separate sheet if necessary)
SIGNATURE DATE JANUARY 6, 2020
CS FORM 212 (Revised 2017), Page 2 of 4
 VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
29. NAME & ADDRESS OF ORGANIZATION
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

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
ATTENDANCE Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
PROGRAMS (Write in full) Supervisory/ (Write in full)
(mm/dd/yyyy) Technical/etc)
From To
Construction Occupational Safety and Health 7/14/2017 1/22/2017 40.0 Technical Department of Labor and Employment

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full) (Write in full)

Drafting N/A N/A

Drawing N/A N/A

CADD/3D modeling N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 6, 2020
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 by
YES ✘ NO
any court or tribunal? If YES, give details:
________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation, retirement, YES ✘ NO
dropped from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in If YES, give details:
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
Hon. Juluis Caesar Vaquilar Andres Bonifacio Diffun Quirino N/A 3.5 cm. X 4.5 cm
(passport size)
Engr. Orlando A. Davin San Marcos Cabarroguis Quirino N/A
With full and handwritten
name tag and signature over
Jessie Delio Vaquilar Rizal, Diffun, Quirino N/A printed name

42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete Computer generated
or photocopied picture
statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. I is not acceptable
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.

PHOTO

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

PLEASE INDICATE ID Number and Date of Issuance

Government Issued ID: VOTERS ID

ID/License/Passport No.: 5703-0055B-80588ERR-10000
Signature (Sign inside the box)
JANUARY 6, 2020
Date/Place of Issuance: Oct.2011/Rizal,Diffun,Quirino
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this JANUARY6,2020 , affiant exhibiting his/her validly issued government ID as indicated above.

ANGELINA D. AMBONON, DPA.

Person Administering Oath

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