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CS Form No.

212
Revised 2017

PERSONAL DATA SHEET


WARNING: Any misinterpretation 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 DELA CRUZ
NAME EXTENSION (JR., SR) N/A
FIRST NAME JUAN

MIDDLE NAME LEE


3. DATE OF BIRTH
(mm/dd/yyyy) 12/25/1990 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH TOLOSA, LEYTTE If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

✘ Single Married 17. RESIDENTIAL ADDRESS N/A N/A


6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
Other/s: N/A TELEGRAFO
Subdivision/Village Barangay
TOLOSA LEYTE
7. HEIGHT (m) 1.65
City/Municipality Province
8. WEIGHT (kg) 73 ZIP CODE 6503

18. PERMANENT ADDRESS N/A N/A


9. BLOOD TYPE "O"
House/Block/Lot No. Street
N/A TELEGRAFO
10. GSIS ID NO. N/A
Subdivision/Village Barangay
TOLOSA LEYTE
11. PAG-IBIG ID NO. 1211-7739-2137
City/Municipality Province

12. PHILHEALTH NO. 03-025506975-2 ZIP CODE 6503

13. SSS NO. 0111-79181645-5 19. TELEPHONE NO. N/A

14. TIN NO. 445-649-502 20. MOBILE NO. 09165732737

15. AGENCY EMPLOYEE NO. 20150800374 21. E-MAIL ADDRESS (if any) facebook@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/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME N/A N/A KEILLAH JANELLE BENJAMIN 8/7/2015

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME BENJAMIN


NAME EXTENSION (JR., SR)
FIRST NAME MARIO N/A

MIDDLE NAME AMISCUA

25. MOTHER'S MAIDEN NAME SABALLE

SURNAME BENJAMIN

FIRST NAME LUZVIMINDA

MIDDLE NAME GONZAGA (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) MIDDLE INITIAL
full) (if not graduated) RECEIVED
From To
DO NOT INDICATE

ELEMENTARY SAN JUAN ELEMENTARY SCHOOL PRIMARY EDUCATION 1999 2005 GRADUATED 2005 N/A

SECONDARY
VOCATIONAL / MANILA NATIONAL HIGH SCHOOL HIGH SCHOOL 2005 2009 GRADUATED 2009 N/A

ELECTRICAL INSTALLATION AND


TESDA TACLOBAN CITY
MAINTENANCE NCII
2014 2014 GRADUATED 2014 N/A
TRADE
COURSE
COLLEGE LUZON STATE UNIVERSITY BACHELOR OF SCIENCE IN CRIMINOLOGY 2009 2013 GRADUATED 2013 CUM LAUDE

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

(Continue on separate sheet if necessary)

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


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

SPO EXAM (NAPOLCOM) 90.0 4/15/2018 TACLOBAN CITY

PO EXAM 89.0 10/22/2017 TACLOBAN CITY

CRIMINOLOGIST 95.0 10/1/2013 TACLOBAN CITY

P.D 907 N/A N/A PALO, LEYTE

(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
(Write in full/Do not (Write in SALARY
applicable)& STEP
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To

PHILIPPINE NATIONAL POLICE/ POLICE


TO POLICE CORPORAL/
7/1/2019 PRESENT REGIONAL OFFICE 8/ REGIONAL MOBILE 29,688.00 10-0
ASSISTANT ADMIN PNCO FORCE BATTALION8

PHILIPPINE NATIONAL POLICE/ POLICE


PATROLMAN/
3/25/2019 6/30/2019 REGIONAL OFFICE 8/ REGIONAL MOBILE 29,688.00 10-0
ASSISTANT ADMIN PNCO FORCE BATTALION8

PHILIPPINE NATIONAL POLICE/ POLICE


REGIONAL OFFICE 8/ REGIONAL PUBLIC
1/16/2017 3/24/2019 POLICE OFFICER 1 SAFETY BATTALION 8/ PUBLIC SAFETY 29,688.00 10-0
COMPANY

7/1/2015 1/15/2017 POLICE OFFICER 1 PHILIPPINE NATIONAL POLICE 14,183.00 10-0


INDICATE INDICATE THE
YOUR DATE SIGNED
(Continue on separate sheet if necessary)
SIGNATURE
SIGNATURE DATE CS FORM 212 (Revised
LICENSE (if applicable)

NUMBER Date of
Validity

N/A N/A

N/A N/A

0092802 N/A

100108140370 4/2/2013

e on separate sheet if necessary)

of duties should be indicated in the attached Work Experience sheet. GOV'T


SERVICE

STATUS OF
APPOINTMENT

(Y/
N)

PERMANENT YES

PERMANENT YES

PERMANEN
YES
T

TEMPORAR
YES
Y
e on 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 POSITIO
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/ CONDUCT
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To

PATROL OFFICER BASIC COURSE 4/11/2017 4/28/2017 80 HOURS SUPERVISORY REGI

PNP SPECIAL COUNTER-INSURGENCY OPERATION UNIT TRAINING 9/16/2016 11/24/2016 360 HOURS SPECIALIZED REGI
REGION
PUBLIC SAFETY FIELD TRAINING PROGRAM 7/1/2015 7/8/2016 1920 HOURS TECHNICAL

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


3
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 3
(Write in full)
.

PUBLIC
COMPUTER LITERATE MEDALYA NG KASANAYAN-5
PUBL
MEDALYA NG PAPURI-6

MEDALYA NG PAGLILINGKOD SA VISAYAS-2

LETTER OF COMMENDATION-20

MEDALYA NG PAGLABAN SA MANLILIGALIG-3

TSAPA NG NATATANGING YUNIT-1


INDICATE INDICATE THE
YOUR DATE SIGNED
SIGNATURE
(Continue on separate sheet if necessary)

SIGNATURE DATE
NT / PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

N/A

on separate sheet if necessary)

G PROGRAMS ATTENDED
e last five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

REGIONAL SPECIAL TRAINING UNIT 8

REGIONAL SPECIAL TRAINING UNIT 8


REGIONAL TRAINING CENTER 8/ REGIONAL
SPECIAL TRAINING UNIT 8

on separate sheet if necessary)


MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in full)

PUBLIC SAFETY MUTUAL BENEFIT FUND,


INC.
PUBLIC SAFETY SAVINGS AND LOAN
ASSOCIATION, INC.

INDICATE THE
DATE SIGNED
on separate sheet if necessary)

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 by NO
YES ✘
any court or tribunal?
If YES, give details:
________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation, retirement, YES ✘ NO
dropped from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in If YES, give details:
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: SAMPLE
c.
ONLY
Are you a solo parent? YES NO
✘ NOTE: IN
If YES, please specify ID No: GOA
UNIFORM
41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAME ADDRESS TEL. NO.


ID picture taken within
the last 6 months
RODRIGO DUTERTE DAVAO CITY 0909090909 3.5 cm. X 4.5 cm
(passport size)

JOSEPH ESTRADA SAN JUAN MANILA 0919191919 With full and handwritten
name tag and signature over
printed name
RONALD DELA ROSA DAVAO CITY 0912646245
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete or photocopied picture
is not acceptable
statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. I authorize the RONALD B DELA
agency head / authorized representative to verify/validate the contents stated herein. I agree that any misrepresentation ROSA
made in this document and its attachments shall cause the filing of administrative/criminal case/s against me. PHOTO

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.) INDICATE
PLEASE INDICATE ID Number and Date of Issuance YOUR
Government Issued ID: PNP ID SIGNATURE

ID/License/Passport No.: 15F5G64F


Signature (Sign inside the box)

Date/Place of Issuance: 12/12/2020


Date Accomplished Right Thumbmark

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

Person Administering Oath

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