Team Supervisor Division Chief

CS Form No. ***

Revised ****

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 PICAÑA

FIRST NAME JASPER

MIDDLE NAME PLANA

3. DATE OF BIRTH

(mm/dd/yyyy) 16. CITIZENSHIP

4/22/1999

FILIPINO

4. PLACE OF BIRTH IWAYAN, ORAS, EASTERN SAMAR If holder of dual citizenship, Pls. indicate country:

please indicate the details.

5. SEX MALE

17. RESIDENTIAL ADDRESS ZONE 4

6 CIVIL STATUS SINGLE

House/Block/Lot No. Street

IWAYAN

Subdivision/Village Barangay

7. HEIGHT (m) 1. 59 m ORAS EASTERN SAMAR

City/Municipality Province

8. WEIGHT (kg) 62 kg ZIP CODE 6818

18. PERMANENT ADDRESS ZONE 4

9. BLOOD TYPE O+

House/Block/Lot No. Street

10. GSIS ID NO. N/A IWAYAN

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121********* ORAS EASTERN SAMAR

City/Municipality Province

12. PHILHEALTH NO. 13-250168753-0 ZIP CODE 6818

13. SSS NO. 34-901****-*-**. TELEPHONE NO. N/A

14. TIN NO. 745-***-***-*** 20. MOBILE NO. 092********

15. AGENCY EMPLOYEE NO. N/A 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)

NAME EXTENSION (JR., SR) N/A

FIRST NAME N/A 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 PICAÑA

NAME EXTENSION (JR., SR)

FIRST NAME PEDRO WILMAR

MIDDLE NAME NOFIES

25. MOTHER'S MAIDEN NAME EVA DELMONTE PLANA

SURNAME PICAÑA

FIRST NAME EVA

MIDDLE NAME PLANA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL HIGHEST LEVEL/

26. PERIOD OF ATTENDANCE YEAR SCHOLARSHIP/

LEVEL (Write in BASIC EDUCATION/DEGREE/COURSE UNITS

GRADUATED ACADEMIC HONORS

full) (Write in full) EARNED RECEIVED

(if not graduated)

NAME OF SCHOOL HIGHEST LEVEL/

YEAR SCHOLARSHIP/

LEVEL (Write in BASIC EDUCATION/DEGREE/COURSE UNITS

GRADUATED ACADEMIC HONORS

full) (Write in full) EARNED RECEIVED

(if not graduated)

From To

ELEMENTARY IWAYAN ELEMENTARY SCHOOL PRIMARY 2005 2011 GRADUATE 2011 WITH HONOR

SECONDARY

VOCATIONAL /

ORAS NATIONAL HIGH SCHOOL SECONDARY 2011 2015 GRADUATE 2015 N/A

N/A N/A N/A N/A N/A N/A N/A

TRADE

COURSE

COLLEGE EASTERN SAMAR STATE UNIVERSITY TERTIARY 2015 5/31/2019 GRADUATE 2019 N/A

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. LICENSE (if applicable)

CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF

RATING

SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT

(If Applicable) NUMBER Date of

BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

Validity

LICENSURE EXAM FOR TEACHER 78.0 9/29/2019 TACLOBAN CITY 1853472 04/22/2023

(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

yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if

MONTHLY STATUS OF

(Write in full/Do not (Write in SALARY

applicable)& STEP

APPOINTMENT

abbreviate) full/Do not abbreviate) (Format "00-0")/

INCREMENT

From To

(Y/ N)

9/1/2020 9/31/2020 Team Supervisor Philippine Statistics Authority 15000.00 650 /day Application 2020

10/5/2020 3/31/2021 Provincial Paid Teacher Provincial Governor's Office 3600.00 300 /day Application 2021

(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

JUNIOR ELEMENTARY EDUCATOR OF THE PHILIPPINES AUG.2017 AUG.2018 N/A VICE PRESIDENT

ORAS YOUTH LEADERS AUG. 2018 PRESENT N/A TREASURER

PROVINCIAL YOUTH LEADERS 7/1/2018 PRESENT N/A MUNICIPAL REPRESENTATIVE

(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

30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE Type of LD

NUMBER OF HOURS

( Managerial/ CONDUCTED/ SPONSORED BY

(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)

Technical/etc)

From To

N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMBERSHIP IN ASSOCIATION/ORGANIZATION

31. SPECIAL SKILLS and HOBBIES 32. 33. (Write in

(Write in full) full)

Computer Literate N/A JUNIOR ELEMENTARY EDUCATOR OF THE PHILIPPINES

Reading Stories ORAS YOUTH LEADERS

Teaching little children PROVINCIAL YOUTH LEADERS

Oras Civic Society Network

(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, Yes No

a. within the third degree?

b. within the fourth degree (for Local Government Unit - Career Employees)?

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 Yes No

last 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: Yes No

a. Are you a member of any indigenous group?

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

EDGAR JULUS LIM BORONGAN CITY E. S 907-***-**** (passport size)

With full and handwritten

JOSEPHINE MARASIGAN BORONGAN CITY E. S 905-***-**** name tag and signature over

printed name

Computer generated

MA. ISABEL G. LAPESURA ORAS E. S 926-***-**** or photocopied picture

is not acceptable

42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and

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/criminal case/s against me. PHOTO

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of Issuance

Government Issued ID: TIN ID

ID/License/Passport No.: 745-***-***-***

Signature (Sign inside the box)

Date/Place of Issuance: 06/26/2019 BORONGAN 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

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