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
I. PERSONAL INFORMATION
2. SURNAME SOLAIMAN
NAME EXTENSION (JR., SR)
FIRST NAME MONERA N/A

MIDDLE NAME ABAS

3. DATE OF BIRTH
(mm/dd/yyyy) NOV 03,2001 16. CITIZENSHIP
✘ Filipino Dual Citizenship

✘ by birth by naturali
4. PLACE OF BIRTH Brgy.Resa D.O.S If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX
Male ✘ Female
6 CIVIL STATUS
17. RESIDENTIAL ADDRESS N/A N/A
✘ Single Married House/Block/Lot No. Street
Widowed Separate TENORIO AWANG
Other/s: d
Subdivision/Village Barangay

7. HEIGHT (m) 154.4cm DATU ODIN SINSUAT MAGUINDANAO

City/Municipality Province
8. WEIGHT (kg) 54kg ZIP CODE 9600

9. BLOOD TYPE A+' 18. PERMANENT ADDRESS N/A N/A

House/Block/Lot No. Street
TENORIO AWANG
10. GSIS ID NO. N/A
Subdivision/Village Barangay
DATU ODIN SINSUAT MAGUINDANAO
11. PAG-IBIG ID NO. N/A
City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 9601

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

14. TIN NO. N/A 20. MOBILE NO. 09360438620

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yy
NAME EXTENSION (JR., SR
FIRST NAME N/A N/A N/A

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME SOLAIMAN

NAME EXTENSION (JR., SR)
FIRST NAME UBAS N/A

MIDDLE NAME ABAS

25. ZENAIDA ABAS DACULA

SURNAME ABAS

FIRST NAME ZENAIDA

MIDDLE NAME DACULA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST LEVEL/
26. NAME OF SCHOOL PERIOD OF ATTENDANCE YEAR
LEVEL (Write in BASIC EDUCATION/DEGREE/COURSE
(Write in full)
UNITS
GRADUATED
full) EARNED
(if not graduated)
From To

ELEMENTARY TAMONTAKA ELEMENTARY PRIMARY EDUCATION 2014 2016 N/A 2016

VOCATIONAL
SECONDARY / CANIZARES NATIONAL HIGH SCHOOL HIGH SCHOOL 2016 2020 N/A 2020

AMA COMPUTER COLLEGE SENIOR HIGH SCHOOL 2020 2022 N/A 2022
TRADE
COURSE
COLLEGE DR P. OCAMPO COLLAGES INC. MIDWIFERY 2022 2024 N/A N/A

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE June 29, 2024

CS FORM 212 (Revised 2017), Page

AL DATA SHEET
Experience Sheet shall cause the filing of administrative/criminal case/s against the person

DS) BEFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

N/A

Dual Citizenship

by naturalization
Pls. indicate country:

N/A
Street
AWANG
Barangay
MAGUINDANAO
Province
9600
N/A
Street
AWANG
Barangay
MAGUINDANAO
Province

N/A

09360438620

[email protected]

DATE OF BIRTH (mm/dd/yyyy)

N/A

(Continue on separate sheet if necessary)

SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED

DIPLOMA

DIPLOMA

DIPLOMA

N/A

N/A
ue on separate sheet if necessary)

June 29, 2024

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

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

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

(Continue on separate sheet if necessary)

SIGNATURE DATE June 29, 2024

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

WORK IMMERSION 06/1/2021 06/3/2021 ON THE JOB TRAINING

RED CROSS 6/10/2024 6/11/2024 ON THE JOB TRAINING

PEER COUNSELORS 11/19/2023 6/22/2024 ON THE JOB TRAINING

COTABATO REGIONAL MEDICAL CENTER 02/18/2024 03/30/2024 300.0 ON THE JOB TRAINING

(Continue on separate sheet if necessary)

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

RED CROSS 6/10/2024 6/11/2024 2DAYS

HIV SEMINAR 3/10/2024 3/11/2024 2DAYS

CANCER 5/12/2024 5/12/2024 1DAY

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. NON-ACADEMIC DISTINCTIONS / RECOGNITION (Write in full) 33. (Write in
full)

BUSINESS N/A N/A

COOKING N/A N/A

HOUSEKEEPING N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE June 29, 2024

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

✘
b. within the fourth degree (for Local Government Unit - Career Employees)? YES
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
out (abolition) in the public or private sector? If YES, give details:
________________________________
________________________________
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
RASUL SALANDUYAN COTABATO CITY 9359046185 4.5 cm. X 3.5 cm
(passport size)
BAITATA SOLAIMAN SEMBA D.O.S MAG. 9971220380
Computer generated
or photocopied picture
BAIMUS A. MAKMOD COTABATO CITY 09971736889 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:

ID/License/Passport No.:
Signature (Sign inside the box)
June 29, 2024
Date/Place of Issuance:
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