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 aga
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. (D

I. PERSONAL INFORMATION
2. SURNAME MANAGA
NAME EXTENSION (JR.,
FIRST NAME MARK EDGAR
MIDDLE NAME MURILLO N/A
3. DATE OF BIRTH
(mm/dd/yyyy) 11/4/1990 16. CITIZENSHIP Filipino Dual Citizenship
by birth b
4. PLACE OF BIRTH MAASIN, SOUTHERN LEYTE If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male Female

6 CIVIL STATUS
Single Married 17. RESIDENTIAL ADDRESS N/A PU
Widowed Separated House/Block/Lot No.

Other/s:
N/A U
Subdivision/Village Ba
7. HEIGHT (m) 1. 64 SAN FRANCISCO SOUTH
City/Municipality P
8. WEIGHT (kg) 67 ZIP CODE 6613

9. BLOOD TYPE "B" 18. PERMANENT ADDRESS N/A PU

House/Block/Lot No.

10. GSIS ID NO. N/A N/A U

Subdivision/Village Ba

11. PAG-IBIG ID NO. 1211- 5537- 7830 SAN FRANCISCO SOUTH

City/Municipality P

12. PHILHEALTH NO. 1305- 0176- 8392 ZIP CODE 6613

13. SSS NO. 13- 5421442- 3 19. TELEPHONE NO. N/A

14. TIN NO. 475- 586- 370 20. MOBILE NO. 09068511167

15. AGENCY EMPLOYEE NO. 2017- 300 21. E-MAIL ADDRESS (if any) Markedgar.managa@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)
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 MANAGA
NAME EXTENSION (JR., SR)
FIRST NAME EDGAR
MIDDLE NAME BURDEOS N/A
25. MOTHER'S MAIDEN NAME

SURNAME MURILLO
FIRST NAME ANGELITA
MIDDLE NAME SOLIMA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

SAN FRANCISCO CENTRAL ELEMENTARY

ELEMENTARY PRIMARY 1998 2004 GRADUATED
SCHOOL

SECONDARY PANAON INSTITUTE HIGH SCHOOL 2004 2008 GRADUATED

 N/A N/A N/A N/A N/A
TRADE
BACHELOR OF SCIENCE IN
COURSE
COLLEGE SAINT JOSEPH COLLEGE 2008 2014 GRADUATED
CRIMINOLOGY

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

(Continue on separate sheet if necessary)

SIGNATURE DATE 05
CS FOR
 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)

N/A

Dual Citizenship

by naturalization

Pls. indicate country:

PUROK 1
Street
UBOS
Barangay
SOUTHERN LEYTE
Province
6613
PUROK 1
Street
UBOS
Barangay
SOUTHERN LEYTE
Province

6613

N/A

09068511167

Markedgar.managa@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

N/A

11/ 11/ 1956

12/ 13/ 1954

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2004 N/A

2008 N/A
 N/A N/A

2014 N/A

N/A N/A
parate sheet if necessary)

05/29/17
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (if ap
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

CRIMINOLOGIST/ RA 6506 76. 25% 10/ 19- 21/ 2014 CAGAYAN DE ORO CITY 0112222

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

7/4/2016 TO DATE POLICE TRAINEE PHILIPPINE NATIONAL POLICE 14, 000.00 10-0 RENEWAL
TEMPORARY
10/5/2015 2/5/2016 CCTV OPERATOR METRO RETAIL STORES GROUP INC. 7, 000.00 N/A CONTRACTUAL

(Continue on separate sheet if necessary)

SIGNATURE DATE 05/29/2017
CS FORM 212 (Revised 20
 LICENSE (if applicable)

Date of
Validity

###

arate sheet if necessary)

GOV'T
SERVICE

(Y/
N)
YES

NO

arate sheet if necessary)

05/29/2017
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 /
From To

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 PROGRAMS ( Managerial/ CONDUCTED/
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To
7/4/2016 1/19/2017 960 HOURS PHILIPP
PUBLIC SAFETY BASIC RECRUIT COURSE (PHASE 1 ) N/A REGI

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERS
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

BASKETBAL N/A

SINGING AND DANCING

DRIVING
 (Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

N/A

eparate sheet if necessary)

ROGRAMS ATTENDED
five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

PHILIPPINE PUBLIC SAFETY COLLEGE

REGIONAL TRAINING CENTER 7

eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

N/A
eparate sheet if necessary)

05/29/17
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
MALAPOC NORTE, MAASIN CITY, the last 6 months
REGEL C. MULLET SOUTHERN LEYTE
9062502044 3.5 cm. X 4.5 cm
(passport size)
PASANON, SAN FRANCISCO, SOUTHERN
METCHI I. SUAREZ LEYTE 9265327399 With full and handwritten
name tag and signature over
printed name
AMPARO, MACROHON, SOUTHERN
PCINSP RAUL G. MARAON (Ret.), MPA LEYTE
9328655678 Computer generated
or photocopied picture
is not acceptable
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct 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 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: DRIVER'S LICENSE
ID/License/Passport No.: H05- 12- 000870 Signature (Sign inside the box)
05/29/17
Date/Place of Issuance: 11/ 13/ 2014/ QUEZON CITY 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 o

 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