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.
1. CS ID No.
Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE. (Do not fill up. For CSC use only)
I. PERSONAL INFORMATION
2. SURNAME OBIENA
NAME EXTENSION (JR., SR)
FIRST NAME KELVIN KENDREW

MIDDLE NAME ORALE

3. DATE OF BIRTH
(mm/dd/yyyy) 7/14/2006 16. CITIZENSHIP
Filipino [✓] Dual Citizenship [ ]
by birth [. ] by naturalization [. ]

4. PLACE OF BIRTH CAN-AVID EASTERN SAMAR If holder of dual citizenship,

please indicate the details.

5. SEX Male [✓] MALE Female [ ]

Single [✓] Married [ ] 17. RESIDENTIAL ADDRESS 00165 JULIO IRASGA STREET
6 CIVIL STATUS SINGLE
Widowed [. ] Separated [. ] House/Block/Lot No. Street
BRGY. 08 POBLACION
Other/s: [. ]
Subdivision/Village Barangay
CAN-AVID EASTERN SAMAR
7. HEIGHT (m) 1.626 meters
City/Municipality Province
8. WEIGHT (kg) 54 kg ZIP CODE 6806

18. PERMANENT ADDRESS 00165 JULIO IRASGA STREET

9. BLOOD TYPE TYPE B
House/Block/Lot No. Street
BRGY. 08 POBLACION
10. GSIS ID NO.
N/A Subdivision/Village Barangay

11. PAG-IBIG ID NO. CAN-AVID EASTERN SAMAR

N/A City/Municipality Province

12. PHILHEALTH NO. ZIP CODE 6806

N/A
13. SSS NO. 19. TELEPHONE NO. 09654461498
N/A
14. TIN NO. 20. MOBILE NO. 09654461498
N/A
15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) kelvinobiena@gmail.com
N/A
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
N/A
NAME EXTENSION (JR., SR)
FIRST NAME
N/A
MIDDLE NAME
N/A
OCCUPATION
N/A
EMPLOYER/BUSINESS NAME
N/A
BUSINESS ADDRESS
N/A
TELEPHONE NO.
N/A
24. FATHER'S SURNAME OBIENA 11/8/1976
NAME EXTENSION (JR., SR)
FIRST NAME OWEN

MIDDLE NAME BALBABOCO

25. MOTHER'S MAIDEN NAME

SURNAME ORALE 4/18/1976

FIRST NAME MELY

MIDDLE NAME ABANAG (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY CAN-AVID CENTRAL ELEMENTARY SCHOOL 6/13/2013 4/15/2019 N/A 2019 N/A
N/A
SECONDARY CAN-AVID NATIONAL HIGH SCHOOL 6/10/2019 6/14/2023 N/A 2025 N/A
VOCATIONAL / N/A
N/A N/A N/A N/A
N/A N/A
TRADE COURSE
COLLEGE N/A N/A N/A N/A
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
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

(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
SERVICE
28. INCLUSIVE DATES SALARY/ JOB/ PAY
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY GRADE (if STATUS OF
(Write in SALARY
applicable)& STEP
APPOINTMENT
full/Do not abbreviate) (Write in full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To
(Y/ N)

(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) NUMBER OF HOURS POSITION / NATURE OF WORK
(mm/dd/yyyy)
From To

(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

(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)

(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,
YES [. ] NO [✓]
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or If YES, give details:
phased 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)? YES [. ] NO [✓]
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the YES [. ] NO [✓]
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?
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
ANNIE SUZETTE D. CAÑAZARES BRGY. CANTEROS CAN-AVID the last 6 months
EASTERN SAMAR 9126042903 4.5 cm. X 3.5 cm
(passport size)
BRGY. CAROLINA CAN-AVID EASTERN
NORIETA R. AVILA SAMAR 9293051700 Computer generated
or photocopied picture
BRGY. 03 DOLORES EASTERN SAMAR is not acceptable
DOMINICA P. DIOLOA 9305228643
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