Sie sind auf Seite 1von 5

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 BARBA
N/A
FIRST NAME ODHESSA ROSS

MIDDLE NAME BATAN


3. DATE OF BIRTH
(mm/dd/yyyy)
4/17/1999 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH Amulung, Cagayan If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS NONE


Widowed Separate House/Block/Lot No. Street
d Concepcion
Other/s:
Subdivision/Village Barangay
Amulung Cagayan
7. HEIGHT (m) 158
City/Municipality Province
8. WEIGHT (kg) 53.3 ZIP CODE 3505

18. PERMANENT ADDRESS NONE


9. BLOOD TYPE AB +
House/Block/Lot No. Street
Concepcion
10. GSIS ID NO. N/A
Subdivision/Village Barangay
Amulung Cagayan
11. PAG-IBIG ID NO. N/A
City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 3505

13. SSS NO. N/A 19. TELEPHONE NO. NONE

14. TIN NO. 146-849-120-000 20. MOBILE NO.

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any)

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)
N/A N/A
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 BARBA


N/A
FIRST NAME JOEHERSON

MIDDLE NAME ANDRES

25. MOTHER'S MAIDEN NAME TABISORA

SURNAME BARBA

FIRST NAME WINNIE

MIDDLE NAME BATAN (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND


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

ELEMENTARY CONCEPCION ELEMENTARY SCHOOL Primary Education 2005 2012

SECONDARY
VOCATIONAL / AMULUNG NATIONAL HIGH SCHOOL High School 2012 2015

NONE
TRADE
BACHELOR POF SCIENCE IN
COURSE
COLLEGE SAINT PAUL UNIVERSITY PHILIPPINES 2015 2019
INFORMATION TECHNOLOGY

GRADUATE STUDIES

(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 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

(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
28. INCLUSIVE DATES (mm/dd/ SALARY/ JOB/ PAY SERVICE
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
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)

07/01/19 PRESENT CLERK LOCAL GOVERNMENT UNIT AMULUNG 7700 JOB ORDER

(Continue on separate sheet if necessary)

SIGNATURE DATE
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

ALUMNI,EXTERNAL RELATIONS AND ADVOCACIES ORGANIZATION 7/2/2019 7/5/2019 MARKETING STAFF

PAULINIAN STUDENT GOVERNMENT UNIWIDE 9/4/2015 7/14/2017 SITE,ASSOCIATE JUSTICE

PAULINIAN STUDENT GOVERNMENT SCHOOLIWIDE 10/12/2017 7/14/2018 SITE GOVERNOR

(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
THE EMERGING WORLD OF DATA SCIENCE 04/26/18 04/27/18 16HRS TECHNICAL SAINT PAUL UNIVERSITY PHILIPPINES
TCON4-PITCH PLEASE:ENVISION,ENGAGE,ENRICH 12/02/18 12/02/18 8HRS TECHNICAL SAINT PAUL UNIVERSITY PHILIPPINES
OVERVIEW OF CIPM CERTIFICATION 12/08/18 12/08/18 8HRS TECHNICAL COMPTIA,ICDL,EC-COUNCIL
CURRENT TRENDS IN CYBERSECURITY 12/08/18 12/08/18 8HRS TECHNICAL COMPTIA,ICDL,EC-COUNCIL
DATA PRIVACY ISSUES AND COMPLIANCE 12/08/18 12/08/18 8HRS TECHNICAL COMPTIA,ICDL,EC-COUNCIL
HOT TOPICS IN CYBERSECURITY 12/08/18 12/08/18 8HRS TECHNICAL COMPTIA,ICDL,EC-COUNCIL
CYBER SECURITY CERTIFICATIONS 12/08/18 12/08/18 8HRS TECHNICAL COMPTIA,ICDL,EC-COUNCIL
TOP 5 CONCERNS IN DATA PRIVACY 12/08/18 12/08/18 8HRS TECHNICAL COMPTIA,ICDL,EC-COUNCIL
AI MACHINE LEARNING IN BROWSER SING ADVANCED JAVASCRIPT 01/16/19 01/16/19 8HRS TECHNICAL SAINT PAUL UNIVERSITY PHILIPPINES
BUILDING MOBILE APPLICATION USING IONIC ON ANDROID AND IOS 01/17/19 01/17/19 8HRS TECHNICAL SAINT PAUL UNIVERSITY PHILIPPINES
INTERNET OF THINGS USING ARDUINO APPLICATION 06/03/19 06/04/19 16HRS TECHNICAL SAINT PAUL UNIVERSITY PHILIPPINES

(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 in
(Write in full)
full)

USING COMPUTER PROGRAMS TO DESIGN

SETTING UP NETWORKS

PARTICIPATING IN FUND RAISING EVENTS

ATTENDING SEMINARS

LEARNING NEW SKILLS

(Continue on separate sheet if necessary)


SIGNATURE DATE
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
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten


name tag and signature over
printed name

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 administrative/ PHOTO
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:

ID/License/Passport No.:
Signature (Sign inside the box)

Date/Place of Issuance:
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

Das könnte Ihnen auch gefallen