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 BADUA
NAME EXTENSION (JR., SR)
FIRST NAME LESLIE

MIDDLE NAME VALDEZ

3. DATE OF BIRTH
7/10/1965 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH SAN NICOLAS, ILOCOS NORTE If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS

House/Block/Lot No. Street
Separat
Widowed BARANGAY 14
Other/s: ed Subdivision/Village Barangay
BATAC CITY ILOCOS NORTE
7. HEIGHT (m) 1.57
City/Municipality Province
8. WEIGHT (kg) 65 ZIP CODE

18. PERMANENT ADDRESS

9. BLOOD TYPE O
House/Block/Lot No. Street
BARANGAY 14
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 912290119110 BATAC CITY ILOCOS NORTE

City/Municipality Province

12. PHILHEALTH NO. 05-025268412-0 ZIP CODE

13. SSS NO. 0107616481 19. TELEPHONE NO. N/A

14. TIN NO. 133-425-098 20. MOBILE NO. 09195090729

15. AGENCY EMPLOYEE NO. 21 (P)- INIMO-13 21. E-MAIL ADDRESS (if any) N/A

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME BADUA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) ELOISA JOY B. BADUA
FIRST NAME MARITES 09/22/1993
LEMUEL B. BADUA
MIDDLE NAME BAGAOISAN 11/24/1999
MARIENELL B. BADUA
OCCUPATION BUSINESS 5/1/2002

EMPLOYER/BUSINESS NAME LEMUEL GEN. MERCHANDISE

BUSINESS ADDRESS BRGY. 14, BATAC CITY

TELEPHONE NO. N/A

24. FATHER'S SURNAME BADUA

NAME EXTENSION (JR., SR)
FIRST NAME VICTORINO

MIDDLE NAME DADIZ

25. MOTHER'S MAIDEN NAME

SURNAME VALDEZ

FIRST NAME ESTRELITA

MIDDLE NAME (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
HONORS
(Write in full)
full) (if not graduated) RECEIVED
From To

SAN NICOLAS ELEMENTARY SCHOOL,SAN

ELEMENTARY
NICOLAS ILOCOS NORTE
PRIMARY 1972 1978 GRADUATED 1978

ILOCOS NORTE NATIONAL HIGH SCHOOL,

SECONDARY /
VOCATIONAL LAOAG CITY
HIGH SCHOOL 1978 1982 GRADUATED 1982

TRADE
BACHELOR OF SCIENCE IN CIVIL
COURSE
COLLEGE NORTHWESTERN COLLEGE, LAOAG CITY
ENGINEERING
1982 1987 GRADUATED OCT. 1987

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE OCTOBER 25, 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
ILOCOS NORTE COLLEGE OF ARTS TRADE,
NC-II ELECTRICAL INST.AND MAINTENANCE 4/28/20
LAOAG 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. 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 not (Write in SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To (Y/
N)
NATIONAL IRRIGATION ADMINISTRATION-
3/1/2019 6/28/2019 ENGINEERING AIDE A ILOCOS NORTE IRRIG. MANAGEMENT OFFICE
629/D DAILY YES
NATIONAL IRRIGATION ADMINISTRATION-
2/7/2018 12/28/2018 ENGINEERING AIDE A ILOCOS NORTE IRRIG. MANAGEMENT OFFICE
629/D DAILY YES
NATIONAL IRRIGATION ADMINISTRATION-
3/1/2018 6/29/2018 ENGINEERING AIDE A ILOCOS NORTE IRRIG. MANAGEMENT OFFICE
629/D DAILY YES
NATIONAL IRRIGATION ADMINISTRATION-
07/13/2017 12/29/2017 ENGINEERING AIDE A ILOCOS NORTE IRRIG. MANAGEMENT OFFICE
629/D DAILY YES
NATIONAL IRRIGATION ADMINISTRATION-
2/1/2017 06/30/2017 ENGINEERING AIDE A ILOCOS NORTE IRRIG. MANAGEMENT OFFICE
629/D DAILY YES
NATIONAL IRRIGATION ADMINISTRATION-
1/7/2016 12/28/2016 ENGINEERING AIDE A ILOCOS NORTE IRRIG. MANAGEMENT OFFICE
587/D DAILY YES
NATIONAL IRRIGATION ADMINISTRATION-
4/1/2016 06/30/2016 ENGINEERING AIDE A ILOCOS NORTE IRRIG. MANAGEMENT OFFICE
587/D DAILY YES
NATIONAL IRRIGATION ADMINISTRATION-
1/7/2015 12/28/2015 ENGINEERING AIDE A ILOCOS NORTE IRRIG. MANAGEMENT OFFICE
587/D DAILY YES
NATIONAL IRRIGATION ADMINISTRATION-
05/20/2015 06/30/2015 ENGINEERING AIDE A ILOCOS NORTE IRRIG. MANAGEMENT OFFICE
587/D DAILY YES
NATIONAL IRRIGATION ADMINISTRATION-
09/14/2014 12/29/2014 ENGINEERING ASSISTANT A ILOCOS NORTE IRRIG. MANAGEMENT OFFICE
665/D JOB ORDER NO
NATIONAL IRRIGATION ADMINISTRATION-
3/24/2014 9/14/2014 ENGINEERING ASSISTANT A ILOCOS NORTE IRRIG. MANAGEMENT OFFICE
665/D JOB ORDER NO
NATIONAL IRRIGATION ADMINISTRATION-
2/1/2014 3/14/2014 ENGINEERING ASSISTANT A ILOCOS NORTE IRRIG. MANAGEMENT OFFICE
665/D JOB ORDER NO
NATIONAL IRRIGATION ADMINISTRATION-
8/10/2013 12/29/2013 ENGINEERING ASSISTANT A ILOCOS NORTE IRRIG. MANAGEMENT OFFICE
665/D JOB ORDER NO
NATIONAL IRRIGATION ADMINISTRATION-
3/25/2013 9/20/2013 ENGINEERING ASSISTANT A ILOCOS NORTE IRRIG. MANAGEMENT OFFICE
665/D JOB ORDER NO
NATIONAL IRRIGATION ADMINISTRATION-
2/1/2013 3/16/2013 ENGINEERING ASSISTANT A ILOCOS NORTE IRRIG. MANAGEMENT OFFICE
665/D JOB ORDER NO
NATIONAL IRRIGATION ADMINISTRATION-
1/10/2012 12/28/2012 ENGINEERING ASSISTANT A ILOCOS NORTE IRRIG. MANAGEMENT OFFICE
665/D JOB ORDER NO
NATIONAL IRRIGATION ADMINISTRATION-
8/22/2012 9/30/2012 ENGINEERING ASSISTANT A ILOCOS NORTE IRRIG. MANAGEMENT OFFICE
587/D JOB ORDER NO
NATIONAL IRRIGATION ADMINISTRATION
1/16/1989 6/30/2000 ENGINEERING ASSISTANT A PROVINCIAL IRIIGATION OFFICE
276/D DAILY YES

(Continue on separate sheet if necessary)

SIGNATURE DATE OCTOBER 25, 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

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

TRAINING ON GEO-TAGGING 11/25/2013 11/27/2013 NIA - REGION I URDANETA CITY

TRAINING ON MATERIAL TESTING AND QUALITY FOR EMBANKMENT DAM 5/21/2013 5/23/2013 NIA - SRIP CENTRAL OFFICE

NIA - CENTRAL OFFICE DESIGN & SPEC.

TRAINING ON DESIGN OF EARTH DAM 2 MONTHS (1991)
DIVISION
NIA - REGION I DESIGN SECTION URDANETA
TRAINING ON DESIGN OF CANAL, CANAL STRUCTURES AND DIVERSION DAM 3 MONTHS (1990)
CITY

(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)

DRAFTING N/A N/A

BASKETBALL

(Continue on separate sheet if necessary)

SIGNATURE DATE OCTOBER 25, 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 ✘
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? ________________________________
________________________________
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
ANNALISA M. BAGAOISAN BRGY. 14, BATAC CITY 09175760305 3.5 cm. X 4.5 cm
(passport size)

REV. NOEL R. MORALES BRGY. 13, BATAC CITY 09759719921 With full and handwritten
name tag and signature over
BRGY. 15 SAN NICOLAS, ILOCOS printed name
PASTOR JESS GOMEZ NORTE
09187830593
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied picture
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: DRIVERS LICENSE
DANILO V. GOMEZ
DIVISION MANAGER A
ID/License/Passport No.: A03-99-041464
Signature (Sign inside the box)
OCTOBER 25, 2019
Date/Place of Issuance: 10/07/2019 / LAOAG 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 of 4