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 Van Tongelen
      FIRST NAME David NAME EXTENSION (JR., SR)
      MIDDLE NAME Catibo
 3.  DATE OF BIRTH 1994-01-10 16. CITIZENSHIP
      (mm/dd/yyyy)   Filipino   Dual Citizenship
 by birth  by naturalization
 4.  PLACE OF BIRTH If holder of  dual citizenship,            Pls. indicate country:
please indicate the details.
 5.  SEX Male Female
House Residence street resid
 6. CIVIL STATUS Single Married 17. RESIDENTIAL ADDRESS
Widowed Separated House/Block/Lot No. Street
street brgy
Other/s:
Subdivision/Village Barangay
 7. HEIGHT (m)   city province
City/Municipality Province
 8.  WEIGHT (kg) ZIP CODE     zip resid
 9.  BLOOD TYPE 18. PERMANENT ADDRESS house perm street perm
House/Block/Lot No. Street
 10. GSIS ID NO. subd perm brgy perm
Subdivision/Village Barangay
 11.  PAG-IBIG ID NO. city perm prov perm
City/Municipality Province
 12.  PHILHEALTH NO. ZIP CODE     zip perm
 13.  SSS NO. 19. TELEPHONE NO.
 14. TIN NO. 20. MOBILE NO.
 15.  AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any)
II.  FAMILY BACKGROUND
22. SPOUSE\'S SURNAME 23. NAME of CHILDREN  (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy) 
      FIRST NAME NAME EXTENSION (JR., SR)
 
      MIDDLE NAME
     OCCUPATION
     EMPLOYER/BUSINESS NAME
     BUSINESS ADDRESS
     TELEPHONE NO.
24. FATHER\'S SURNAME
     FIRST NAME NAME EXTENSION (JR., SR)
 
     MIDDLE NAME
25. MOTHER\'S MAIDEN NAME
     SURNAME
     FIRST NAME
     MIDDLE NAME (Continue on separate sheet if necessary)
III.  EDUCATIONAL BACKGROUND
26.   NAME OF SCHOOL
(Write in full)		 BASIC EDUCATION/DEGREE/COURSE
(Write in full)		 PERIOD OF ATTENDANCE HIGHEST
LEVEL/UNITS
EARNED
(if not graduated)		 YEAR
GRADUATED		 SCHOLARSHIP/ ACADEMIC HONORS RECEIVED
LEVEL
From To
(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
SPECIAL LAWS/ CES/ CSEE
BARANGAY ELIGIBILITY / DRIVER'S LICENSE		 RATING
(If Applicable)		 DATE OF
EXAMINATION /
CONFERMENT		 PLACE OF EXAMINATION / CONFERMENT LICENSE (if applicable)
NUMBER Date of
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.
28. INCLUSIVE DATES
(mm/dd/yyyy)		 POSITION TITLE
(Write in full/Do not abbreviate)		 DEPARTMENT / AGENCY / OFFICE / COMPANY
(Write in full/Do not abbreviate)		 MONTHLY
SALARY		 SALARY/ JOB/
PAY GRADE (if
applicable)& STEP
(Format"00-0")/
INCREMENT		 STATUS OF
APPOINTMENT		 GOV'T
SERVICE
(Y/ N)
From To
(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
29. NAME & ADDRESS OF ORGANIZATION
(Write in full)		 INCLUSIVE DATES
(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
(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)
TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS
(Write in full)		 INCLUSIVE DATES OF
ATTENDANCE
(mm/dd/yyyy)		 NUMBER OF
HOURS		 Type of LD
( Managerial/
Supervisory/
Technical/etc)		 CONDUCTED/ SPONSORED BY
(Write in full)
30.
  From To
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
31. SPECIAL SKILLS and HOBBIES 32. NON-ACADEMIC DISTINCTIONS / RECOGNITION
(Write in full)		 33. MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in full)
(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?
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 out (abolition) in the public or private sector? YES NO
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 election to promote/actively campaign for a national or local candidate? YES NO
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
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
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)
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