CS Form No.

212
Revised 2017 Unique Applicant Number
PERSONAL DATA SHEET T15185502
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 DEOCAMPO
NAME EXTENSION (JR., SR)
FIRST NAME KHERSTIE

MIDDLE NAME CATALAN

3. DATE OF BIRTH
(mm/dd/yyyy) 05/02/21987 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by by
✘
birth naturalization
4. PLACE OF BIRTH POB. ILYA, MAAYON, CAPIZ If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female
17. RESIDENTIAL ADDRESS
6 CIVIL STATUS ✘ Single Married
House/Block/Lot No. Street
Widowed Separat
NONE POBLACION TABUC
Other/s: ed Subdivision/Village Barangay
MAAYON CAPIZ
7. HEIGHT (m) 1.54
City/Municipality Province
8. WEIGHT (kg) 86.7 ZIP CODE 5809

18. PERMANENT ADDRESS NONE None

9. BLOOD TYPE 0
House/Block/Lot No. Street
NONE POBLACION TABUC
10. GSIS ID NO. 2005303720
Subdivision/Village Barangay
MAAYON CAPIZ
11. PAG-IBIG ID NO. 1211-238265-62
City/Municipality Province

12. PHILHEALTH NO. 110504361284 ZIP CODE 5809

13. SSS NO. 07-2409597-7 19. TELEPHONE NO. NONE

14. TIN NO. 439-405-014 20. MOBILE NO. 09199740849

15. AGENCY EMPLOYEE NO. 6312265 21. E-MAIL ADDRESS (if any) khestieviannette27@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) NONE
FIRST NAME NONE

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME DEOCAMPO

NAME EXTENSION (JR., SR)
FIRST NAME MAMERTO

MIDDLE NAME DALMINO

25. MOTHER'S MAIDEN NAME

SURNAME CATALAN

FIRST NAME ROSEMARIE

MIDDLE NAME BATILARAN (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY MAAYON ELEMENTARY SCHOOL PRIMARY 6/1/1995 4/1/2000 2000 NONE

SECONDARY
VOCATIONAL / MAAYON NATIONAL HIGH SCHOOL SECONDARY 6/1/2000 3/30/2004 2004 NONE

TRADE
BACHELOR OF ARTS MAJOR IN CHED
COURSE
COLLEGE FILAMER CHRISTIAN COLLEGE 6/1/2004 4/3/2008 2008
POLITICAL SCIENCE SCHOLARSHIP

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE September 5, 2019

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 applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity

LET (LICENSURE EXAMINATION FOR TEACHERS) MANILA 1470239 5/2/2022

(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. GOV'T
SALARY/ JOB/ SERVICE
28. INCLUSIVE DATES PAY GRADE (if
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY applicable)& STATUS OF
(Write in full/Do not (Write in SALARY STEP (Format APPOINTMENT
abbreviate) full/Do not abbreviate) "00-0")/
From To INCREMENT
(Y/
N)
NONE

(Continue on separate sheet if necessary)

SIGNATURE DATE SEPTEMBER 5, 2019

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

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

(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)

COOKING

READING BOOKS

COMPUTER LITERATE

SINGING

(Continue on separate sheet if necessary)

SIGNATURE DATE SEPTEMBER 5, 2019

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
the last 6 months
ATTY. SERGIE V. GEVERO PUBLIC ATTORNEY'S OFFICE, CAPIZ 9082873006 3.5 cm. X 4.5 cm
(passport size)
TALISAY POLYTECHNIC INSTITUTE,
MRS. MARICEL DEADE BATANGAS
9303325339 With full and handwritten
name tag and signature over
printed name
ATTY. ROELB. DAPITON PAO, ILOILO CITY 9062344605
Computer generated
42. or photocopied picture
I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and is not acceptable
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: License ID

ID/License/Passport No.: 1470239

Signature (Sign inside the box)
09/05/2079
Date/Place of Issuance: Iloilo City
Date Accomplished Right Thumbmark

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

MA. SHARON S. BARRIENTOS

Person Administering Oath

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