Agricultural Technician

CS Form No. ***

Revised ****

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 CAPUYAN

NAME EXTENSION (JR., SR)

FIRST NAME EDGAR

MIDDLE NAME BENTOY

3. DATE OF BIRTH

5/2/1992 16. CITIZENSHIP

(mm/dd/yyyy) Filipino Dual Citizenship

by by

birth naturalization

4. PLACE OF BIRTH Danao City, Cebu 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

Widowed Separate

Panaligan Street Camilmil

Other/s: d

Subdivision/Village Barangay

Calapan Oriental Mindoro

7. HEIGHT (m) 0.127

City/Municipality Province

8. WEIGHT (kg) 75 ZIP CODE

18. PERMANENT ADDRESS House/Block/Lot No. Street

9. BLOOD TYPE AB

Panaligan Street Camilmil

10. GSIS ID NO. N/A

Subdivision/Village Barangay

Calapan Oriental Mindoro

11. PAG-IBIG ID NO. N/A

City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 5200

13. SSS NO. 343-***-**** 19. TELEPHONE NO.

14. TIN NO. 457-***-***-**. MOBILE NO. 095********

15. AGENCY EMPLOYEE NO. 90 21. E-MAIL ADDRESS (if any) ************@*****.***

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME CAPUYAN 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME NAME EXTENSION (JR., SR) ARYA EMILY, CAPUYAN 6/25/2020

CHRISTINE JOY

MIDDLE NAME 7/6/1992

REYES

OCCUPATION Government Eployee

EMPLOYER/BUSINESS NAME Department of Agriculture-MIMAROPA

BUSINESS ADDRESS 3rd floor, ATI Building, Elliptical Road, diliman, Quezon City

TELEPHONE NO. 920-43-50

24. FATHER'S SURNAME CAPUYAN 1/29/1954

NAME EXTENSION (JR., SR)

FIRST NAME LEONITO

MIDDLE NAME SINGSON

25. MOTHER'S MAIDEN NAME

SURNAME CAPUYAN 12/2/1953

FIRST NAME LILIOSA

MIDDLE NAME ENRIQUEZ (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL HIGHEST LEVEL/ SCHOLARSHIP/

26. PERIOD OF ATTENDANCE YEAR

LEVEL (Write in BASIC EDUCATION/DEGREE/COURSE

(Write in full)

UNITS

GRADUATED

ACADEMIC

full) EARNED HONORS

(if not graduated) RECEIVED

From To

ELEMENTARY Rodriguez Heights Elementary School Elementary 2000 2004 Graduated 2004

SECONDARY Montalban Heights National High School High School 2004 2008 Graduated 2008

VOCATIONAL /

TRADE

COURSE

COLLEGE University of Rizal System- (Rodriguez Campus) Bachelor of Agricultural Technology 2008 2012 Graduated 2012

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE October 26, 2020 CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY

27. LICENSE (if applicable)

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

SPECIAL LAWS/ CES/ CSEE (If Applicable) EXAMINATION / PLACE OF EXAMINATION / CONFERMENT

BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT NUMBER Date of

Validity

N/A

N/A

N/A

N/A

N/A

N/A

N/A

(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)

6/1/2015 present Agricultural Technician II Department of Agriculture -MIMAROPA 14,931.00 Job Order

9/1/2014 5/31/2015 Admin Aide Department of Agriculture -MIMAROPA 12,921.00 Job Order

10/1/2013 3/31/2014 Checker Collonade Supermarket 8,000.00

6/1/2012 9/31/2012 Farm Manager Rizal Poultry 8,000.00

(Continue on separate sheet if necessary)

SIGNATURE DATE October 26, 2020 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. NUMBER OF

NAME & ADDRESS OF ORGANIZATION (Write in full) HOURS POSITION / NATURE OF WORK

(mm/dd/yyyy)

From To

N/A

N/A

N/A

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 (Write NUMBER OF ( Managerial/ CONDUCTED/ SPONSORED BY

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

Technical/etc)

From To

Agricultural Training Institute (VSU) Phlippine

Syposium on the Advances of Cassava and other Root Crop Researches and Workshop on Identification of possible 3-20-2019 3-21-2019 16 Technical Root Crop

research areas and Technologies for training.

Training on Image Acquisition and Processing using DJI Phantom 4 Pro 01-22-2019 01-25-2019 40 Technical Department of Agriculuture

04/24/2018 04/27/2018 32 Technical

Project Procurement Management Plan and Annual Procurement Plan SCCE Training Center

National Public Consultative Meeting for the Development of Philippine National Standards for Various Agricultural

Machinery

10/9/2017 10/12/2017 32 Technical

Bureau of Agricultural and Fisheries Standards

8/14/2017 8/18/2017 40 Technical

Training on Corn Cluster Development Plan and Good Agricultural Practices in Corn Department of Agriculuture

3/22/2017 3/25/2017 32 Technical

Regional Capacity Building Towards Germplasm Utilization: Evaluating for Abiotic Stress Tolerance in Corn University of the Philippines

5/24/2016 5/26/2016 24 Tech. Department of Agriculuture

Training on Writeshop for the Regional Chicken & Swine Situation Reports

10/27/2015 10/28/2015 16 Tech. Department of Agriculuture

Training on Cassava Processing and Good Manifacturing Practices

8/24/2015 8/28/2015 32 Tech. Department of Agriculuture

Training on Seed Production & Certification on OPV Corn for Seed

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN

31. SPECIAL SKILLS and HOBBIES 32. NON-ACADEMIC DISTINCTIONS / RECOGNITION 33. ASSOCIATION/ORGANIZATION

(Write in full)

(Write in full)

Basketball N/A N/A

Singing N/A N/A

Dancing N/A N/A

Travel N/A N/A

N/A N/A

N/A N/A

N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE October 26,2020 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 any court or tribunal? YES NO

If YES, give details:

37. Have you ever been separated from the service in any of the following modes: resignation,

retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased YES NO

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

Barangay election)? YES NO

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

JUPITER TIVIDAD San Jose, Occ. Mindoro 918-***-**** 3.5 cm. X 4.5 cm

(passport size)

JOSELITO NAVARRO Montalban, Rizal 909-***-**** With full and handwritten

name tag and signature over

printed name

ENGR. MA. CHRISTINE C. INTING Manila 927-***-****

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

statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. I is not acceptable

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: Company I.D

ID/License/Passport No.: 90

Signature (Sign inside the box)

October 26,2020

Date/Place of Issuance: Quezon, 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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