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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 SIBAL
NAME EXTENSION (JR., SR)
FIRST NAME JOHN EXEQUIEL

MIDDLE NAME SIBAL


3. DATE OF BIRTH
(mm/dd/yyyy) 6/20/1995 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH TUGUEGARAO CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

✘ Single Married 17. RESIDENTIAL ADDRESS 313 MARUZZO


6 CIVIL STATUS
House/Block/Lot No. Street
Widowed Separated
BUNTUN
Other/s: Subdivision/Village Barangay
TUGUEGARAO CAGAYAN
7. HEIGHT (m) 1.62
City/Municipality Province
8. WEIGHT (kg) 53 ZIP CODE 3500

18. PERMANENT ADDRESS 313 MARUZZO


9. BLOOD TYPE O+
House/Block/Lot No. Street
BUNTUN
10. GSIS ID NO. NONE
Subdivision/Village Barangay
TUGUEGARAO CAGAYAN
11. PAG-IBIG ID NO. 1211-0617-6009
City/Municipality Province

12. PHILHEALTH NO. 06-25216556-0 ZIP CODE 3500

13. SSS NO. NONE 19. TELEPHONE NO. 078-846-3370

14. TIN NO. 315-838-709-000 20. MOBILE NO. 09218956662

15. AGENCY EMPLOYEE NO. 2833 21. E-MAIL ADDRESS (if any) jesibal0629@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME NONE 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME NONE AL GREGORY ADAM TABERNA SIBAL 1/29/2014

MIDDLE NAME NONE

OCCUPATION NONE

EMPLOYER/BUSINESS NAME NONE

BUSINESS ADDRESS NONE

TELEPHONE NO. NONE

24. FATHER'S SURNAME SIBAL


NAME EXTENSION (JR., SR)
FIRST NAME ALLAN

MIDDLE NAME LAGUTA

25. MOTHER'S MAIDEN NAME GUADALUPE TALATTAD TUMBALI

SURNAME SIBAL

FIRST NAME GUADALUPE

MIDDLE NAME TUMBALI (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND


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

ELEMENTARY TUGUEGARAO WEST CENTRAL SCHOOL ELEMENTARY 6/11/2001 3/9/2007 GRADUATED 2007 NONE

SECONDARY /
VOCATIONAL SAN JACINTO SEMINARY SECONDARY 6/18/2007 3/21/2011 GRADUATED 2011 NONE

NONE NONE

TRADE
B.S. BUSINESS ADMINISTRATION MAJOR IN
COURSE
COLLEGE CAGAYAN STATE UNIVERSITY
MANAGEMENT ACCOUNTING
### 6/15/2016 GRADUATED 2016 NONE

CAGAYAN STATE UNIVERSITY - COLLEGE OF


GRADUATE STUDIES
LAW
BACHELOR OF LAWS AND LETTERS 6/27/2016 PRESENT 84

(Continue on separate sheet if necessary)

SIGNATURE DATE June 08 ,2018

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

20021505077
CAREER SERVICE PROFESSIONAL 83.6 6/15/2015 TUGUEGARAO CITY
70301

(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

CONTRACT
9/4/2017 PRESENT CLERK CAGAYAN VALLEY MEDICAL CENTER 7000.00 N/A
OF SERVICE
CONTRACT
3/1/2016 2/17/2017 BOOK-KEEPER THOM SOYA FOOD PRODUCTS 6000.00 N/A
OF SERVICE
CAGAYAN STATE UNIVERSITY - COLLEGE OF BUSINESS, ENTREPRENEURSHIP
3/9/2015 5/22/2015 ON-THE-JOB-TRAINEE AND ACCOUNTANCY N/A N/A OJT
CONTRACT
12/9/2013 1/23/2014 CALL SERVICE REPRESENTATIVE JOLIBEE FOODS CORPORATION 4000-4500 N/A
OF SERVICE
(Continue on separate sheet if necessary)

SIGNATURE DATE June 08 ,2018


LICENSE (if applicable)

Date of
Validity

arate sheet if necessary)

GOV'T
SERVICE

(Y/
N)
NO

NO

NO

NO
arate sheet if necessary)
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

NONE

(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

LUSOG ISIP SEMINAR, MENTAL HEALTH CELEBRATION 10/21/2017 10/21/2017 8.0 TECHNICAL CAGAYAN VALLEY MEDICAL CENTER

CENTER FOR HEALTH DEVELOPMENT REGION


BASIC LIFE SUPPORT 3/7/2017 3/8/2017 16.0 TECHNICAL
2

(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
(Write in full)
in full)
RECOGNITION - DANCE CHOREOGRAPHER, GIVEN ON DECEMBER 27, 2017 AT
CREW CAPTAIN - FIRED UP CAGAYAN
COMPUTER LITERATE
CAGAYAN VALLEY MEDICAL CENTER DANCE TROUPE
APPRECIATION - JUDGE, GIVEN ON JANUARY 20,2016 AT CAGAYAN STATE
MEMBER - ATHENA DEBATE AND MOOT
DANCING, SINGING AND MUSIC SKILLS
UNIVERSITY COURT SOCIETY
EVENTS ORGANIZER - CBEA (CSU) 2015-
LOGICAL AND COMPREHENSIVE SKILLS NATIONAL FINALIST - CREW LEADER, PHILIPPINE HIPHOP CHAMPIONSHIPS 2016
2016
CHAMPION, CREW LEADER - CAGAYAN STATE UNIVERSITY INTRAMURALS 2014- CAPTAIN - BADMINTON AND VOLLEYBALL
FAST DATA ORGANIZATION AND ENCODING
2015 TEAM (SBAA-USLT) 2012-2014
COLLEGE SPORTS COORDINATOR (SBAA-
ATHLETICALLY INCLINED RECOGNITION - SECOND PLACER, LOUISIAN'S GOT TALENT FEBRUARY 15, 2013
USLT) 2012-2014
MEMBER - LOUISIAN DEBATE SOCIETY,
GOOD IN ORAL COMMUNICATION TOPNOTCHER - NATIONAL CAREERS ASSESMENT EXAMINATION, 2011 (99.00%)
2011-2013
CAPTAIN - BADMINTON AND VOLLEYBALL
GOOD PROBLEM SOLVING SKILLS RECOGNITION - ORATOR OF THE YEAR, SAN JACINTO SEMINARY 2009-2011 TEAM (SAN JACINTO SEMINARY) 2008-
2011
(Continue on separate sheet if necessary)

SIGNATURE DATE June 08 ,2018

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 ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘

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? ________________________________
RESIGNED IN JOLIBEE DUE TO PATERN
________________________________
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 w
the last 6 month
PROF. JAYPEE G. ALEGADO CAGAYAN STATE UNIVERSITY (078) 844-0098 3.5 cm. X 4.5 c
(passport size
(078) 302-0000
MELITA T. TAGUIBAO CAGAYAN VALLEY MEDICAL CENTER
loc 403 With full and handw
name tag and signatu
(078) 302-0000 printed name
HAROLD C. TAMAYAO CAGAYAN VALLEY MEDICAL CENTER
loc 788 Computer genera
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied pic
is not acceptab
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: EMPLOYEE ID (cvmc)

ID/License/Passport No.: 2833


Signature (Sign inside the box)
11/14/2017, CAGAYAN VALLEY June 8, 2018
Date/Place of Issuance:
MEDICAL CENTER Date Accomplished Right Thumbma

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

Person Administering Oath

CS FORM 212 (Revise


If YES, give details:
________________________________

If YES, give details:


________________________________
________________________________

If YES, give details:


________________________________
________________________________

If YES, give details:


________________________________
________________________________

If YES, give details:


________________________________
RESIGNED IN JOLIBEE DUE TO PATERNAL DUTIES
________________________________
✘ NO

✘ NO

✘ NO
If YES, give details (country):

✘ NO

✘ NO

✘ 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

Computer generated
or photocopied picture
is not acceptable

PHOTO

Right Thumbmark

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

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