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 u

I. PERSONAL INFORMATION
2. SURNAME RAGONOT

FIRST NAME CARLITO JR

MIDDLE NAME ESTOYA

3. DATE OF BIRTH
16. CITIZENSHIP Filipino Dual Citizenship
(mm/dd/yyyy) 10/27/1986 ✘

✘ by birth by naturalization
4. PLACE OF BIRTH Tacloban City, Leyte If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

✘ Single Married 17. RESIDENTIAL ADDRESS 65-B Esperas Ave., Magallanes St.
6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
Other/s: Brgy. 48-B
Subdivision/Village Barangay

7. HEIGHT (m) Tacloban City Leyte

City/Municipality Province
8. WEIGHT (kg) ZIP CODE 6500

9. BLOOD TYPE o
18. PERMANENT ADDRESS 65-B Esperas Ave., Magallanes St.
House/Block/Lot No. Street

10. GSIS ID NO. Brgy. 48-B

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1211-1683-9595 Tacloban City Leyte

City/Municipality Province

12. PHILHEALTH NO. 13-200959261-3 ZIP CODE 6500

13. SSS NO. 06-2734672-3 19. TELEPHONE NO.

14. TIN NO. 415-093-581 20. MOBILE NO. 09069064684

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) ragonot.carlito86@yahoo.com

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME n/a 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd
NAME EXTENSION (JR., SR)
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 Ragonot

FIRST NAME Carlito Sr

MIDDLE NAME Garcia

25. MOTHER'S MAIDEN NAME

SURNAME Estoya

FIRST NAME Nimfa

MIDDLE NAME Teves (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY Rizal Central School Elementary June 1993 March 1999 graduated 1999

SECONDARY
VOCATIONAL / Leyte National High School Secondary June 1999 March 2003 graduated 2003

TRADE
COURSE
COLLEGE Eastern Visayas State University Tertiary June 2003 March 2007 graduated 2007

GRADUATE STUDIES Leyte Colleges Supplemental - BSED May 2016 October 2017 earned 18 units 2017
(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), P
L DATA SHEET
ence Sheet shall cause the filing of administrative/criminal case/s against the person concerned.

FORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

JR

by naturalization
Pls. indicate country:

Magallanes St.
Street
Brgy. 48-B
Barangay
Leyte
Province
6500
Magallanes St.
Street
Brgy. 48-B
Barangay
Leyte
Province

09069064684

ragonot.carlito86@yahoo.com

DATE OF BIRTH (mm/dd/yyyy)

(Continue on separate sheet if necessary)

SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED
 SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED

graduated

graduated

graduated

earned 18
units
on separate sheet if necessary)

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

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

December 01, 2010 -

Barangay Official Eligibility Brgy. 48-B Tacloban City
November 30,2013

Certification of Eligibility - Professional 80.04% March 18,2018 Tacloban City

Professional Teacher 78.40% March 25,2018 Tacloban City

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

Fresenius Medical Care dba Asia Renal Care Phils.

May 2018 present Payor Specialist P12,000.00 monthly salary
Inc.
September 2016 December 2017 Partner Relations Staff Card Pioneer Microinsurance Inc. P10,000.00 monthly salary

August 2014 March 2016 Sr. Associate WNS Global Services Philippines Inc. P21,000.00 monthly salary

January 2010 July 2014 Biller to Production Supervisor Freight Process Outsourcing Solutions Inc. P10,000.00 monthly salary
Barangay Councilor (Finance and
December 2010 November 2013 Office of the Barangay, Barangay 48-B P4,500.00 honorarium
Appropriations Committee Chairman)
 (Continue on separate sheet if necessary)

SIGNATURE DATE
 LICENSE (if applicable)

NUMBER Date of
Validity

220108140482 July 16,2014

326882 May 16,2018

1668325 August 20,2018

separate sheet if necessary)

GOV'T SERVICE
STATUS OF
APPOINTMENT
(Y/ N)

probationary
N
period
regular N

regular N

regular N

elected Y
separate sheet if necessary)

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

(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 PROGRAMS ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33. (Write in
(Write in full)
full)
 (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 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
,
35. a. Have you ever been found guilty of any administrative offense? give
YES ✘ NO
detai
ls:If
YES
____
,
____
give
YES
____ ✘ NO
b. Have you been criminally charged before any court?
detai
____
ls:If
____
____
YES
____
, Date Filed:
giveStatus of Case/s:
____
36. YES
Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation ____detai
✘ NO
by any court or tribunal? ____
ls:
If YES, give details: ________________________________
____ ________________________________
____
____
____
YES NO
37. Have you ever been separated from the service in any of the following modes: resignation, ✘
____
____
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased
out (abolition) in the public or private sector? ____
If YES, give details: Resignation in my previous employers
____
____
38. YES
____ ✘ NO
a. Have you ever been a candidate in a national or local election held within the last year (except ____
Barangay election)? ____
____
____
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:
____
39. Have you acquired the status of an immigrant or permanent resident of another country? YES
____
✘ NO
____
40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA ____
YES ✘ NO
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. YES ✘ NO
Are you a person with disability?

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
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten

name tag and signature over
printed name

42. Computer generated

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

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

Date/Place of Issuance:
Date Accomplished Right Thumbmark

, affiant exhibiting his/her validly issued government ID as indicated above.

Person Administering Oath

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