PDS
CS FORM 212 (Revised 2005)
PERSONAL DATA SHEET
Print legibly. Mark appropriate boxes
with "
1. CS ID No.
" and use separate sheet if necessary.
(to be filled up by CSC)
I. PERSONAL INFORMATION
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2. SURNAME
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FIRST NAME
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MIDDLE NAME
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GEN. LUNA, LLANERA NUEVA ECIJA
Male
6. SEX
7. CIVIL STATUS
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Widowed
Separated
17. TELEPHONE NO.
Annulled
Others, specify ___________
18. PERMANENT ADDRESS
9. HEIGHT (m)
5'6
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(e.g.
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ZIP CODE
3107
NONE
PUROK 07, BARANGAY, MALIGAYA CABIAO NUEVA ECIJA
10. WEIGHT (kg)
65 KLS.
11. BLOOD TYPE
"A"
19. TELEPHONE NO.
NONE
12. GSIS ID NO.
200 202 7012
20. E-MAIL ADDRESS (if any)
[email protected]
13. PAG-IBIG ID NO.
1210 7290 4950
21. CELLPHONE NO. (if any)
09179170224/ 09282657439
14. PHILHEALTH NO.
070503108524
22. AGENCY EMPLOYEE NO.
80085600
15. SSS NO.
02-1828378-7
23. TIN
219-653-970
ZIP CODE
3107
II. FAMILY BACKGROUND
N/A
25. NAME OF CHILD (Write full name and list all)
FIRST NAME
N/A
PAULA JANE S. RIVERA
09/28/1994
MIDDLE NAME
N/A
PATRICIA ANNE S. RIVERA
06/01/1998
OCCUPATION
N/A
KENSHIN S. MENDOZA
06/21/2005
EMPLOYER/BUS. NAME
N/A
SANJI S. MENDOZA
08/13/2007
BUSINESS ADDRESS
N/A
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TELEPHONE NO.
N/A
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24. SPOUSE'S SURNAME
DATE OF BIRTH (mm/dd/yyyy)
(Continue on separate sheet if necessary)
SISON
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FIRST NAME
ALFREDO
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MIDDLE NAME
CELEBRADOS
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26. FATHER'S SURNAME
27. MOTHER'S MAIDEN NAME
SURNAME
BONILLA
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FIRST NAME
NARCISA
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MIDDLE NAME
TOLENTINO
(Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
28.
LEVEL
NAME OF SCHOOL
(Write in full)
DEGREE COURSE
(Write in full)
YEAR
GRADUATED
(if graduated)
HIGHEST GRADE/
LEVEL/
UNITS EARNED
(if not graduated)
INCLUSIVE DATES OF
ATTENDANCE
From
To
ELEMENTARY
SAN VICENTE ELEMENTARY SCHOOL
PRIMARY
1984
1979
1984
SECONDARY
STO. TOMAS BRGY. HIGH SCHOOL
SECONDARY
1988
1984
1988
VOCATIONAL /
TRADE COURSE
STENOGRAPHY COURSE (GAPAN-TESDA)
2002
5/27/2002
7/19/2002
COLLEGE
GRADUATE STUDIES
UNIVERSITY OF THE ASSUMPTION
LIBERAL ARTSENGLISH MAJOR
1992
1988
1992
ARAULLO UNIVERSITY
BACHELOR OF
LAWS
1997
1993
1997
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Fem ale
Married
FILIPINO
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PUROK 07, BARANGAY, MALIGAYA CABIAO NUEVA ECIJA
Single
8. CITIZENSHIP
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16. RESIDENTIAL ADDRESS
12/18/1971
4. DATE OF BIRTH (mm/dd/yyyy)
5. PLACE OF BIRTH
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SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED
(Continue on separate sheet if necessary)
Page 1 of 4
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