Personal Data Sheet Cs Form No. 212 Revised 2018

 

CS Form No. 212

 

Revised 2018 

PERSONAL PERSONA L DA DAT TA S SHEET HEET WARNING: Any WARNING: Any misrepresentation made in the Personal Data Sheet and the W Work ork Experience Sheet shall cause the fi filing ling of administrative/crimi administrative/criminal nal cas concerned. READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.

Print legibly. Tick appropriat appropriatee boxes (

) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE.

1. CS ID No.

(

I. P E R S O N A L IN FO R MA TIO N 2. SURNAME SURNAME

Estanda

FIRST NAME

Alexis

MIDDLE NAME

Canaway

3. DATE OF BIRTH (mm/dd/yyyy)

NA NAME ME EXTE EXTENS NSIO ION N (J (J

16. CITIZENSHIP

 04/12/1992

 Fi  Filipino

Dual Citizenship by

4. PLACE OF OF BIR BIRTH TH

Midsayap, North Cotabato  Male

 Female

6 CIVIL STATUS STATUS

 Single

 Married

 Widowed

 Separated

please indicate the details.

17. RESIDENTIAL ADDRESS House/Block/Lot No.

Ma

 Other/s: 7. HEIGHT HEIGHT (m) (m) 8. WEIGHT WEIGHT (kg) (kg) 9. BLOO BLOOD D TYP TYPE E 10. GSIS ID NO. NO. 11. 11. PAG-IBIG PAG-IBIG IID D NO.

Subdivision/Village 

P ar a n g

1.67 72kgs "A"

Pls. indicate

If holder of dual citizenship,

5. SEX SEX

Mag u i

City/Municipality 

9604

ZIP CODE 18. PERMANENT ADDRESS House/Block/Lot No.

Po

N/A

Subdivision/Village 

Mi dsa ya p

91-4256005773

N or t h C

City/Municipality 

94 0

12. PHILHEALTH PHILHEALTH NO.

17-050355967-9

13. SSS NO. NO.

N/A

19. TELEPHONE NO.

N/A

14. TIN NO.

463-278-908

20. MOBILE NO.

0906460678 /09072203300

15. AGENCY EMPLOYEE NO.

284987

21. E-MAIL ADDRESS (if any)

[email protected]

ZIP CODE

II. FA MILY MILY B A C K G R O U N D 22. SPOUSE'S SPOUSE'S SURN SURNAME AME

N/A

  FIRST NAME

N/A

  MIDDLE MID DLE NAME

N/A

OCCUPATION

N/A

EMPLOYER/BUSINESS NAME

N/A

BUSINESS ADDRESS

N/A

TELEPHONE NO.

N/A

24. FATHE FATHER'S R'S SU SURNA RNAME ME

23. NAME of CHILDREN (Write full name and list all) NAME EXTENSION (JR., SR)

N/A

Estanda

FIRST NAME

Alex

MIDDLE NAME

Pareño

birth

NAME EXTENSION (JR., SR) SR.

N/A

 

25. MOTHER'S MOTHER'S MA MAIDEN IDEN NAME NAME SURNAME

Canaway

FIRST NAME

Zoila

MIDDLE NAME

Cabalfin

(Continue on separate sheet if necessary

III. E D U C A TIO N A L B A C K G R O U N D

 

NAME OF SCHOOL

26.

BASIC EDUCATION/DEGREE/COURSE (Write in (Write in full)

LEVEL

HIGHEST LEVEL/ PERIOD OF ATTENDANCE UNITS EARNED

full) From

To

(if not graduated)

ELEMENTARY

Lt. Andres Calungsud Elementary School

Primary Education

  99 99 9

2 0 05

N /A

SECONDARY  

Vi l l a r i c a H i g h S c h o o l

Hig h Sc ho ol

2005

2 0 09

N /A

N/A

N /A

N/ A

N/ A

N /A

i-Link College of Science and Technology

Bachelor of Science in Criminology

2009

20 3

N /A

N/ N/A A

N/A

N/ A

N/ A

N /A

COLLEGE GRADUATE STUDIES

(Continue on separate sheet if necessary)

S I G N AT U R E

7/26/

D AT E  

CS FO

 

   

/s against the person

Do not fill up. For CSC use only)

N/A

., SR)

by

 

naturalization

country:

Street 

Making Barangay 

Maguindanao Province 

9604 Street 

blacion 8 Barangay 

North Cotabato Province 

94 0 N/A 0906460678 /09072203300

DATE OF BIRTH (mm/dd/yyyy)

 

(Continue on separate sheet if necessary)

  YEAR GRADUATED

SCHOLARSHI P/ ACADEMIC HONORS RECEIVED

2 00 5

N/A

2 00 9

N/A

N/A

N/A

20 3

N/A

N/A

N/A

parate sheet if necessary)

7/26/20 9  

RM 212 (Revised 2018), Page 1 of 4 

 

IV.. C IV IL S E R V IC E E L IG IB IL ITY IV 27.

CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEE BARANGAY ELIGIBILITY / DRIVER'S LICENSE

Criminology Board Exam

LICENSE (if ap

RATING (If Applicable)

DATE OF EXAMINATION / CONFERMENT

PLACE OF EXAMINATION / CONFERMENT

82.95

 04/1/2014

University of Mindanao Matina Davao City

NUMBER

0098956

(Continue on separate sheet if necessary)

V . W O R K E X P E R IE IE N C E (Include private employment. Start from your recent work) Description of duties duties should be indicated in the attached attached Work Experience sheet. 28.

INCLUSIVE DATES (mm/dd/yyyy)

POSITION TITLE

DEPARTMENT / AGENCY / OFFICE / COMPANY (Write in full/Do not abbreviate)

(Write in full/Do not abbreviate)

SALARY/ JOB/ PAY GRADE (if MONTHLY SALARY applicable)& STEP (Format "00-0")/ INCREMENT

STATUS OF  APPOINTMENT  APPOINTMENT

From

To

01/01/2018

Present

Patrolman

Philippine National Police

29,668.00

10-0

Permanent

11/02/15

12/31/17

Patrolman

Philippine National Police

14,834.00

10-0

Permanent

06/13/14

11/01/15

Patrolman

Philippine National Police

14,834.00

10-0

Temporary

 

( C onti nue on s epar ate s heet i f nec es s ar y )

S I G N AT U R E

D AT E

J ul y 26, 20 9  

CS FORM 212 (Revised 2 

 

 

plicable) Date of  Validity

 04/12/2021

rate sheet if necessary)

  SERVICE

(Y/

Y Y Y

 

rate sheet if necessary) July 26, 20 9  

18), Page 2 of 4 

 

V I . V O L U N TA TA R Y W O R K O R I N V O L V E M E N T I N C I V I C / N O N - G O V E R N M E N T / P E O P L E / V O L U N TA R Y O R G A N I Z A T IO IO N / S INCLUSIVE DATES

29. NAME & ADDRESS OF ORGANIZATION (Write in full)

(mm/dd/yyyy) To

From

i-Link College of Science and Technology

06/01/14

POSITION /

NUMBER OF HOURS

N /A

03/30/16

C ri mi n ol o

(Continue on separate sheet if necessary)

V I I . L E A R N I N G A N D D E V E L O P M E N T ( L & D ) I N T E R VE V E N T I O N S / T R A I N I N G P R O G R A M S AT AT T E N D E D (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 30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS (Write in full)

Public Safety Basic Recruit Course

 ATTENDANCE  ATTENDANCE NUMBER OF HOURS

Type of LD  ( Managerial/ Supervisory/ Technical/etc)

960

Basic

(mm/dd/yyyy) From

To

07/ 07/04 04/1 /16 6

01/1 01/16/ 6/20 2017 17

CONDUCTE

 Autono Mindan

 

(Continue on separate sheet if necessary)

V I I I. I. O T H E R I N F O R M AT AT I O N 31.

SPECIAL SKILLS and HOBBIES

Computer Literate

32.

NON-ACADEMIC DISTINCTIONS / RECOGNITION

33.

(Write in full)

 ASSOC  

Prof Profis issi sion on

Medalya ng Papuri-7

(Continue on separate sheet if necessary)

S I G N AT U R E

D AT E  CS

 

T / P E O P L E / V O L U N TA R Y O R G A N IZA TIO N /S  

ATURE OF WORK

Criminology Instructor

parate sheet if necessary)

ROGRAMS ATTENDED ast five (5) years for Division Chief/Executive/Managerial positions)

 

D/ SPONSORED BY (Write in full)

ous Region and Muslim o Training Center 

 

parate sheet if necessary)

MEMBERSHIP IN IATION/ORGANIZATION (Write in full)

l Criminology Association Association of the Philippines

parate sheet if necessary)

July 26, 20 9  

ORM 212 (Revised 2018), Page 3 of 4

 

34.

 Are you related by consanguinity consanguinity or affinity affinity to the appointing appointing or recommending recommending authority, 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 offens offense? e?

 YE  YES

NO

If YES, give details:

b. Have you been criminally charged before any court?  

 YE  YES

NO

If YES, give details: Date Filed: Status of Case/s:

36.

37.

Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal?

Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped from the rolls, dismissal, dismissal, termination, end of term, finished contract or phased out (abolition) in the public or private sector?

 YE  Y ES

NO

  If YES, give details:

 YE  YES

NO

  If YES, give details:

 Resignation in i-Link College

 of Science and Technolo 38. a. Have you ever been a candidate in a national or local election held within the last year (except Barangay election)?

 YE  YES

b. Have you resigned from the government service during the three (3)-month period before the last election to promote/actively campaign for a national or local candidate? 39.

NO

If YES, give details:  YES

 NO

If YES, give details:

Have you acquired the status of an immigrant or permanent resident of another country?

 YE  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 any indigenous group? b.

 YES

 NO

 YES

 NO

If YES, please specify:

 Are you a person with with disability?

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

PCPT YAZID S ABDULLA PCPT STEPHEN C BONIBA PLT CRISANTO I MANGUBAT

ADDRESS

Parang, Maguindanao Parang, Maguindanao Midayap, North Cotabato

TEL. NO.

09157030560 09751250791 09393488911

42.

Icomplete declare under oath pursuant that I have accomplished thislaws, Personal Sheet whichofisthe a true, correct statement to personally the provisions of pertinent rules Data and regulations Republic of and the Philippines. I authorize the agency head/authorized representative to verify/validate the contents stated herein. I agree that any misrepr misrepresentation esentation made in this this document and its attachments shall cause the filing of administrative/criminal administrativ e/criminal case/s against me.

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

 

(i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.) ov overn ernme menn ss ssue ue PLEASE INDICATE ID Number and Date of Issuance 

Government Issued ID:

PNP ID

ID/License/Passport No.:

17F020553

Date/Place of Issuance:

June 2, 2017

SUBSCRIBED AND SWORN to before me this

Signature (Sign inside the box)

July 26, 2019 Date Accomplished

Right Thumbmark

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

Person Administering Oath CS FORM 212 (Revised 2018), Page 4 of 4