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 adminis
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 AB
I. PERSONAL INFORMATION

2. SURNAME BETONTA

FIRST NAME MARY JOHN PAUL

MIDDLE NAME FUENTES

3. DATE OF BIRTH 8/25/1993 16. CITIZENSHIP Filipino
(mm/dd/yyyy) ✘

4. PLACE OF BIRTH CEBU CITY If holder of dual citizenship,

Male Female please indicate the details.

5. SEX ✘

✘ Single Married 17. RESIDENTIAL ADDRESS

6 CIVIL STATUS
Widowed Separated House/Block/Lot No.
✘ Other/s:
Subdivision/Village
7. HEIGHT (m) 0.165 ARGAO
City/Municipality
8. WEIGHT (kg) 65 ZIP CODE

9. BLOOD TYPE B+ 18. PERMANENT ADDRESS

House/Block/Lot No.
10.GSIS ID NO. 021178273713
Subdivision/Village
11.PAG-IBIG ID NO. 121199528457 ARGAO
City/Municipality
12. PHILHEALTH NO. 122021112451 ZIP CODE 6021

13. SSS NO. NA 19. TELEPHONE NO.

14. TIN NO. 492-712-312-000 20. MOBILE NO.

15. AGENCY EMPLOYEE NO. CAS-053 21. E-MAIL ADDRESS (if any) hauz

II. FAMILY BACKGROUND

23. NAME of CHILDREN (Write
22.SPOUSE'S SURNAME NONE
all)
NAME EXTENSION (JR., SR)
FIRST NAME NONE NA

MIDDLE NAME NONE

OCCUPATION NONE

EMPLOYER/BUSINESS NAME NONE

BUSINESS ADDRESS NONE

TELEPHONE NO. NONE

24.
FATHER'S SURNAME BETONTA
 NAME EXTENSION (JR., SR)
FIRST NAME RODRIGO

MIDDLE NAME TANAID

25.MOTHER'S MAIDEN NAME

SURNAME FUENTES

FIRST NAME SYLVIA

MIDDLE NAME MAMALIAS (Continue on

III. EDUCATIONAL BACKGROUND
NAME OF SCHOOL
BASIC EDUCATION/DEGREE/COURSE PERIOD OF
26.
LEVEL ATTENDANCE
(Write in full) From
(Write in full)
VOCATIONAL TALOOT CENTRAL ELEMENTARY
ELEMENTARY / ELEMENTARY 2000
SCHOOL
CALAGASAN NATIONAL HIGH
SECONDARY SECONDARY 2006
SCHOOL

NA NA

CEBU TECHNOLOGICAL
COLLEGE BS CIVIL ENGINEERING 2010
UNIVERSITY-MAIN CAMPUS
TRADE
GRADUATE
COURSE STUDIES UNIVERSITY OF SAN CARLOS MECE-STRUCTURAL ENGINEERING 2016

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

DS) BEFORE ACCOMPLISHING THE PDS FORM.

1. CS ID No. (Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

✘ Filipino Dual Citizenship

by birth by naturalization

Pls. indicate country:

House/Block/Lot No. Street

TALOOT
Subdivision/Village Barangay
ARGAO CEBU
City/Municipality Province
6021

House/Block/Lot No. Street

TALOOT
Subdivision/Village Barangay
CEBU
City/Municipality Province
6021

NONE

09956136509

hauzlifejef2@gmail.com

23. NAME of CHILDREN (Write full name and list DATE OF BIRTH
all) (mm/dd/yyyy)

NA NA
(Continue on separate sheet if necessary)

HIGHEST
SCHOLARSH
LEVEL/
PERIOD OF YEAR IP/
UNITS
ATTENDANCE GRADUAT ACADEMIC
EARNED
To ED HONORS
(if not
RECEIVED
graduated)
2006 GRADUATED 2006 NONE

VALEDICTO
2010 GRADUATED 2010
RIAN

NA NA NA

2015 GRADUATED 2015 CUM LAUDE

2017 12 UNITS 2016 NONE

DATE January 30, 2018

CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
CAREER SERVICE/ RA 1080 (BOARD/
27. BAR) UNDER SPECIAL LAWS/ CES/ CSEE DATE OF
RATING
EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable)
BARANGAY ELIGIBILITY / DRIVER'S CONFERMENT
LICENSE
CIVIL ENGINEER LICENSURE EXAM 82.6 MAY 2 & 3 2015 CEBU CITY

MATERIALS ENGINEER EXAM 60.0 SEPT. 12, 2015 CEBU CITY

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE
SALARY/
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experien
JOB/ PAY
28. INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / GRADE (if
(mm/dd/yyyy) COMPANY MONTHLY applicable)&
(Write in SALARY STEP
From To full/Do not abbreviate) (Write in full/Do not abbreviate) (Format
"00-0")/
2017 2018 ENGINEERING ASSISTANT LGU-ARGAO 16235.98 INCREMENT
CEBU TECHNOLOGICAL UNIVERSITY-
2016 2017 PART TIME INSTRUCTOR 5000.00
ARGAO CAMPUS
CEBU TECHNOLOGICAL UNIVERSITY-
2016 2017 FULL TIME INSTRUCTOR 19200.00
MAIN CAMPUS
2015 2016 DESIGN ENGINEER GRANBY TRADING & CONSTRUCTION 15000.00
 (Continue on separate sheet if necessary)
SIGNATURE DATE JANUARY 30
CS FORM 212 (Rev
 LICENSE (if applicable)

NUMBER Date of
Validity

0138780 8/25/2018

5198 NONE

separate sheet if necessary)

GOV'T
SERVICE
n of duties should be indicated in the attached Work Experience sheet.

STATUS OF
APPOINTMENT

CASUAL
(Y/ N)
CONTRACTUAL

CONTRACTUAL

PROJECT BASED
separate sheet if necessary)
JANUARY 30, 2018
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENTINCLUSIVE
/ PEOPLE /DATES
VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION
29. NUMBER
(Write in full) POSITION
OF HOURS
From(mm/dd/yyyy)
To

PHILIPPINE INSTITUTE OF CIVIL ENGINEERS

(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 Divisio
positions) INCLUSIVE DATES OF
ATTENDANCE Type of LD
TITLE OF LEARNING AND DEVELOPMENT CONDUC
30. NUMBER ( Managerial/
INTERVENTIONS/TRAINING PROGRAMS
OF HOURS Supervisory/
(Write in full)
From (mm/dd/yyyy)
To Technical/etc)

INTEGRATED WATER RESOURCES MANAGEMENT PLAN NOV. 2017 NOV. 2017 24.0 TECHNICAL
PICE REGIONAL CONVENTION (TECHNICAL SESSION ON WATER
OCT. 2017 OCT. 2017 16.0 TECHNICAL
RESOURCE ENGINEERING)
PICE NATIONAL MID YEAR CONVENTION ( EARTHQUAKE
May-17 May-17 24.0 TECHNICAL
ENGINEERING)
 (Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. (Write 33.
in full)
SINGING NA

DANCING

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM
OPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

MEMBER

parate sheet if necessary)

RAMS ATTENDED
L&D/training taken for the last five (5) years for Division Chief/Executive/Managerial

CONDUCTED/ SPONSORED BY
(Write in
full)

CEBU PROVINCE

PICE REGION 7

PICE-NATIONAL
parate sheet if necessary)

MEMBERSHIP IN
ASSOCIATION/ORGANIZATION

(Write in full)
NA

parate sheet if necessary)

JANUARY 30, 2018
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 YES ✘ NO
regulation by any court or tribunal?
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 YES ✘ NO
Barangay election)? 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 pictu
the la
DR. ROSIEN ANCHETA CEBU CITY NONE 3.5 c
(pas

ENGR. ALEX C. MAYOR CEBU CITY NONE With full

name tag a
prin

Compu
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photo
is no
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 P
filing of administrative/criminal case/s against me.
 Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's
License, etc.) PLEASE INDICATE ID
Number and Date of Issuance
Government Issued ID: PROFESSIONAL REGULATION COMMISSION

ID/License/Passport No.: 0138780 Signature (Sign inside the box)

JANUARY 30, 2018
Date/Place of Issuance: 8/25/2015
Date Accomplished Right T

BSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued govern

Person Administering Oath

CS FORM 212 (Revised

 If YES, give details:

If YES, give details:

________________________________
________________________________

If YES, give details:

________________________________
________________________________

If YES, give details:

________________________________
________________________________

If YES, give details:

________________________________
________________________________
✘ NO

✘ NO

✘ NO
If YES, give details (country):

✘ NO

✘ NO
If YES, please specify ID No:
✘ NO
If YES, please specify ID 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

PHOTO
 Right Thumbmark

, affiant exhibiting his/her validly issued government ID as indicated above.

CS FORM 212 (Revised 2017), Page 4 of 4