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 CAMPILAN
N/A
FIRST NAME MARICEL

MIDDLE NAME FLORES

3. DATE OF BIRTH
(mm/dd/yyyy) 12/5/1984 16. CITIZENSHIP
✘

4. PLACE OF BIRTH PINTUYAN SOUTHERN LEYTE If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘

✘ 17. RESIDENTIAL ADDRESS N/A N/A

6 CIVIL STATUS
House/Block/Lot No. Street
N/A CADARUHAN
Subdivision/Village Barangay
MALITBOG SOUTHERN LEYTE
7. HEIGHT (m) 1.523
City/Municipality Province
8. WEIGHT (kg) 53kg ZIP CODE 6603

18. PERMANENT ADDRESS N/A N/A

9. BLOOD TYPE o
House/Block/Lot No. Street
N/A CADARUHAN
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A MALITBOG SOUTHERN LEYTE

City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 6603

13. SSS NO. 3518803738 19. TELEPHONE NO. N/A

14. TIN NO. 716-235-176 20. MOBILE NO. 09854309738

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME CAMPILAN 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
N/A JEDRICK VINCE FLORES CAMPILAN
FIRST NAME JEFFREY 09/30/2005

MIDDLE NAME BATAS

OCCUPATION DRIVER

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME FLORES

N/A
FIRST NAME VICENTE

MIDDLE NAME MOSOT

25. MOTHER'S MAIDEN NAME

SURNAME ESTRELLA

FIRST NAME ROSITA

MIDDLE NAME MANATAD (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
(Write in full) HONORS
full) (if not graduated) RECEIVED
From To

4TH
ELEMENTARY NUEVA ESTRELLA ELEMENTARY SCHOOL ELEMENTARY 1991 1997 COMPLETED 1997
HONORED

SECONDARY /
VOCATIONAL MARAYAG NATIONAL HIGH SCHOOL HIGH SCHOOL 1997 2001 COMPLETED 2001 N/A

N/A

TRADE
SOUTHERN LEYTE STATE UNIVERSITY-TOMAS
COURSE
COLLEGE
OPPUS
BACHELOR OF ELEMENTARY EDUCATION 2002 2007 COMPLETED 2007 N/A

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 SALARY/ JOB/ PAY SERVICE
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/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)
LOCAL GOVERNMENT UNIT-MALITBOG
1/12/2014 10/30/2025 SANGGUNIANG BARANGAY MEMBER 5168.00 ELECTED YES
SOUTHERN LEYTE

(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

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
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

(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)

CADARUHAN UPLAND WOMENS ASSOCIATION

(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? ✘

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? ✘

If YES, give details:

________________________________
________________________________
b. Have you been criminally charged before any court? ✘

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?
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 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)?
If YES, give details:
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? If YES, give details:
39. Have you acquired the status of an immigrant or permanent resident of another country? ✘

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? ✘
If YES, please specify:
b. Are you a person with disability? ✘
If YES, please specify ID No:
c. Are you a solo parent? ✘
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
CADARUHAN MALITBOG SOUTHERN the last 6 months
JUDIT JOVITA LINGUTAN LEYTE
N/A 4.5 cm. X 3.5 cm
(passport size)
CADARUHAN MALITBOG SOUTHERN
NOLI GONZAGA ICHON LEYTE
N/A
Computer generated
CADARUHAN MALITBOG SOUTHERN or photocopied picture
ANNALYN LACERNA CANDIDO LEYTE
N/A 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 PHOTO
administrative/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: NATIONAL ID

ID/License/Passport No.: 2871-8970-9510-7817

Signature (Sign inside the box)

Date/Place of Issuance: 03/10/2023/CADARUHAN MALITBOG

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