- Reply rate:
- -
- Availability:
- Hourly ($/hour)
- Location:
- Cotabato City, Region Xii, Philippines
- Experience:
- 1 year
CS Form No. 212
Revised 2017
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 A1. CS ID No.
(Do not fill up. For CSC use only)
I. PERSONAL INFORMATION
2. SURNAME
US M A N
FIRST NAME
BA BY A NN
MIDDLE NAME
BOGA
NAME EXTENSION (JR., SR)
3. DATE OF BIRTH
(mm/dd/yyyy)
05/06/1995
4. PLACE OF BIRTH
COTABATO CITY
N/A
16. CITIZENSHIP
Pls. indicate country:
If holder of dual citizenship,
please indicate the details.
5. SEX
02
House/Block/Lot No.
17. RESIDENTIAL ADDRESS
6 CIVIL STATUS
7. HEIGHT (m)
1.62 m
8. WEIGHT (kg)
56 kg
Subdivision/Village
Cotabato City
City/Municipality
9600
ZIP CODE
02
House/Block/Lot No.
18. PERMANENT ADDRESS
O
9. BLOOD TYPE
PASTOR KIMPO ST.
Street
Barangay Rosary Heights XIII
Barangay
Maguindanao
Province
10. GSIS ID NO.
N/A
11. PAG-IBIG ID NO.
N/A
12. PHILHEALTH NO.
N/A
13. SSS NO.
N/A
19. TELEPHONE NO.
14. TIN NO.
N/A
20. MOBILE NO.
15. AGENCY EMPLOYEE NO.
N/A
21. E-MAIL ADDRESS (if any)
PASTOR KIMPO ST.
Street
BARANGAY ROSARY HEIGHTS XIII
Barangay
MAGUINDANAO
Province
9600
Subdivision/Village
COTABATO CITY
City/Municipality
ZIP CODE
N/A
- / --
II. FAMILY BACKGROUND
N/A
N/A
N/A
22. SPOUSE'S SURNAME
FIRST NAME
MIDDLE NAME
23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
N/A
DATE OF BIRTH (mm/dd/yyyy)
N/A
N/A
OCCUPATION
N/A
EMPLOYER/BUSINESS NAME
N/A
BUSINESS ADDRESS
TELEPHONE NO.
N/A
24. FATHER'S SURNAME
USMAN
NAME EXTENSION (JR., SR)
N/A
PANCHO
FIRST NAME
BANDARA
MIDDLE NAME
PARIDA AMBON BOGA
25. MOTHER'S MAIDEN NAME
SURNAME
USMAN
FIRST NAME
PARIDA
BOGA
MIDDLE NAME
(Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
26.
LEVEL
NAME OF SCHOOL
(Write in full)
PERIOD OF ATTENDANCE
HIGHEST LEVEL/
UNITS EARNED
(if not graduated)
YEAR GRADUATED
SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED
From
To
PRIMARY EDUCATION
2002
2008
N/A
2008
N/A
HIGH SCHOOL
2008
2012
N/A
2012
N/A
NOTRE DAME UNIVERSITY
BACHELOR OF SCIENCE IN
ACCOUNTANCY
2012
2014
150
N/A
N/A
NOTRE DAME UNIVERSITY
BACHELOR OF SCIENCE IN CIVIL
ENGINEERING
2014
2019
N/A
2019
N/A
ELEMENTARY
NOTRE DAME RVM COLLEGE OF
COTABATO
SECONDARY
NOTRE DAME RVM COLLEGE OF
COTABATO
VOCATIONAL /
TRADE COURSE
BASIC EDUCATION/DEGREE/COURSE
(Write in full)
N/A
COLLEGE
GRADUATE STUDIES
(Continue on separate sheet if necessary)
SIGNATURE
DATE
December 24, 2019
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27.
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER
SPECIAL LAWS/ CES/ CSEE
BARANGAY ELIGIBILITY / DRIVER'S LICENSE
CIVIL ENGINEERING LICENSURE EXAMINATION
LICENSE (if applicable)
RATING
(If Applicable)
DATE OF
EXAMINATION /
CONFERMENT
PLACE OF EXAMINATION / CONFERMENT
72 %
NOVEMBER 9 TO
10, 2019
PROFESSIONAL REGULATION COMMISSION DAVAO CITY
NUMBER
Date of
Validity
175093
########
(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.
28.
INCLUSIVE DATES
(mm/dd/yyyy)
From
To
POSITION TITLE
(Write in full/Do not abbreviate)
DEPARTMENT / AGENCY / OFFICE /
COMPANY
(Write in full/Do not abbreviate)
SALARY/
GOV'T
MONTHLY JOB/ PAY
STATUS OF
SERVICE
SALARY GRADE (if APPOINTMENT
(Y/ N)
applicable)&
STEP
N/A
(Continue on separate sheet if necessary)
SIGNATURE
DATE
December 26, 2019
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
29.
INCLUSIVE DATES
(mm/dd/yyyy)
NAME & ADDRESS OF ORGANIZATION
(Write in full)
N/A
From
To
N/A
N/A
NUMBER OF
HOURS
POSITION / NATURE OF WORK
N/A
N/A
(Continue on separate sheet if necessary)
VII. LEARNINGAND DEVELOPMENT (L&D) INTERVENTIONS/TRAININGPROGRAMS 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)
30.
TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS
(Write in full)
ON THE JOB TRAINING
INCLUSIVE DATES OF
ATTENDANCE
(mm/dd/yyyy)
From
To
04/11/2018
05/17/2018
NUMBER OF
HOURS
Type of LD
( Managerial/
Supervisory/
Technical/etc)
CONDUCTED/ SPONSORED BY
(Write in full)
240
MINROCK MULTI-BUILDERS
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
31.
SPECIAL SKILLS and HOBBIES
32.
NON-ACADEMIC DISTINCTIONS / RECOGNITION
(Write in full)
33.
COMPUTER LITERATE
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in full)
PHILIPPINE INSTITUE OF CIVIL ENGINEER
COMMUNICATION SKILLS
INTERPERSONAL SKILLS
VOLLEYBALL PLAYER
SOFT BALL PLAYER
(Continue on separate sheet if necessary)
SIGNATURE
DATE
December 26, 2019
CS FORM212 (Revised 2017), Page 3 of 4
34.
Are you related by consanguinity or affinity to the appointing or recommending
chief of bureau or office or to the person who has immediate supervision over you in
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.
37.
38.
39.
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:
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 out (abolition) in the public or private sector?
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:
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
If YES, give details:
candidate?
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?
c.
Are you a solo parent?
If YES, please specify ID No:
If YES, please specify ID No:
41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)
42.
NAME
ADDRESS
TEL. NO.
ENGR. MOHAMMAD A. GUIAPAL, MBA
HK. Doton St. Poblacion 3,
Cotabato City
-
ENGR. AUDREY B. ABA
COTABATO CITY
-
ENGR. JASPER LEY J. OCHIA
St., Doña Luisa 2, Davao City
-
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.
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
Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc
PLEASE INDICATE ID Number and Date of Issuance
Government Issued ID: POSTAL ID
ID/License/Passport NL-
Date/Place of Issuanc COTABATO CITY
SCRIBED AND SWORN to before me this.
BABY ANN B. USMAN
Signature (Sign inside the box)
12/26/2019
Date Accomplished
Right Thumbmark
, affiant exhibiting his/her validly issued government ID as indicated ab
Person Administering Oath
CS FORM212(Revised2017), Page 4of 4
Yes/No
Yes
No
Cstat
Gender
Single
Male
Married Female
Separated
Widowed
