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 aga
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

I. PERSONAL INFORMATION
2. SURNAME PELAYO
NAME EXTENSION (JR., SR)
FIRST NAME EMELITO

MIDDLE NAME CRISOLOGO

3. DATE OF BIRTH
(mm/dd/yyyy) 1/21/1960 16. CITIZENSHIP ✘ Filipino Dual Citizenship
✘ by birth by
4. PLACE OF BIRTH BACOOR CITY, CAVITE If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX ✘ Male Female

Single ✘ Married 17. RESIDENTIAL ADDRESS #92

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. S
GA
Other/s:
Subdivision/Village Bar
KAWIT CA
7. HEIGHT (m) 1.71
City/Municipality Pro
8. WEIGHT (kg) 75 ZIP CODE

18. PERMANENT ADDRESS 101 TIRON

9. BLOOD TYPE O
House/Block/Lot No. S
DULON
10. GSIS ID NO. BP# 2001392649
Subdivision/Village Bar
BACOOR CITY
11. PAG-IBIG ID NO. 1030-0009-9275
City/Municipality Pro

12. PHILHEALTH NO. 0800-0079-6763 ZIP CODE 4102

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 223-631-597 20. MOBILE NO. 09988607086

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) pelayoemil.211@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME PELAYO 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) VIEN ADRIAN V. PELAYO
FIRST NAME EMELINDA

MIDDLE NAME RAMOS VIEN LIONEL V. PELAYO

OCCUPATION HOUSEMAKER JAVEE ANNE V. PELAYO

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME PELAYO

NAME EXTENSION (JR., SR)
FIRST NAME BIENVENIDO

MIDDLE NAME CASTILLO

25. MOTHER'S MAIDEN NAME JACINTA PAMUTI CRISOLOGO

SURNAME PELAYO

FIRST NAME JACINTA

MIDDLE NAME CRISOLOGO (Continue on separate sheet if necessary

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY DULONG BAYAN ELEMENTARY SCHOOL PRIMARY 1966 1972 GRADUATED

SECONDARY /
VOCATIONAL ST. ANDREW'S SCHOOL SECONDARY 1972 1976 GRADUATED

FAR EASTERN UNIVERSITY MEDICAL TECHNOLOGY 1976 1979 2ND YEAR

TRADE
COURSE BACHELOR OF ARTS MAJOR IN MASS
COLLEGE SAN SEBASTIAN COLLEGE
COMMUNICATIONS 1993 1996 GRADUATED

GRADUATE STUDIES SAN BEDA COLLEGE BACHELOR OF LAWS 1996 2001 GRADUATED

(Continue on separate sheet if necessary)

SIGNATURE DATE CS FORM 212 (Rev

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

EFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Dual Citizenship

by naturalization

Pls. indicate country:

Street
GAHAK
Barangay
CAVITE
Province

TIRONA HI-WAY
Street
DULONG BAYAN
Barangay
CAVITE
Province

09988607086

pelayoemil.211@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

7/8/1989

5/15/1990

12/24/1994
 (Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

1972

1976

1996

2001

parate sheet if necessary)

CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable)
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

BAR 75.1 3/21/2003 MANILA

(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 SALARY/ JOB/ PAY
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY
(Write in full/Do not (Write in SALARY
applicable)& STEP
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To

1/3/2019 PRESENT MARKETING SUPERVISOR V PROVINCIAL GOVERNMENT OF CAVITE 65969.00 24-1

HOUSING AND HOME SITE
3/15/2010 12/31/2018 PROVINCIAL GOVERNMENT OF CAVITE 54234.00 22-3
REGULATION OFFICER V
1/1/2009 3/15/2010 ADMINISTRATIVE OFFICER V PROVINCIAL GOVERNMENT OF CAVITE 28000.00 18-1

10/24/2005 1/1/2009 LEGAL OFFICER II PROVINCIAL GOVERNMENT OF CAVITE 15000.00 17-2

1/1/2003 10/23/2005 PRIVATE PRACTICE N/A N/A N/A

12/1/1984 7/30/1991 MEDICAL RECORDS TECHNICIAN KING KHALID UNIVERSITY HOSPITAL USD 500 N/A

1/1/1983 12/31/1983 MEDICAL RECORDS TECHNICIAN MAKATI MEDICAL CENTER 300.00 N/A
 (Continue on separate sheet if necessary)

SIGNATURE DATE CS FORM 212 (Revised

 LICENSE (if applicable)

NUMBER Date of
Validity

48257

e on separate sheet if necessary)

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

SERVICE

STATUS OF
APPOINTMENT

(Y/
N)
PERMANENT YES

PERMANENT YES

PERMANENT YES

PERMANENT YES

N/A NO

PERMANENT NO

CASUAL NO
e on separate sheet if necessary)

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 / N
From To

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

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

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

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

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

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

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

(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)
INCLUSIVE DATES OF
ATTENDANCE Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ( Managerial/ CONDUCTED/ S
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To
LIGHT RAIL MA
PROJECT INTER-AGENCY COMMITTEE PLANNING SESSION 4/20/2017 4/21/2017 16 PROFESSIONAL AUTHORITY

CIVIL SERVICE
SUPERVISORY DEVELOPMENT COURSE TRACK 1 3/28/2017 3/31/2017 32 SUPERVISORY RESOURCE

DEPARTME
POLICY REVIEW AND WRITE SHOP FOR CAVITE CLUSTER 11/15/2016 11/16/2016 16 PROFESSIONAL

4TH COOPERATIVE LEADERS' CONFERENCE "COOPERATIVE DEVELOPMENT PROVINCIAL

10/18/2016 10/18/2016 8 MANAGERIAL
AGENDA 2020" ENTREPRE
TRAINING COURSE ON ISO 9001:2015 QUALITY MANAGEMENT SYSTEMS
10/12/2016 10/12/2016 8 QUALITY PROVINCI
REQUIREMENT AND DOCUMENTATION
RESETTLEMENT ACTION PLANNING WORKSHOP FOR RECEIVING LOCAL DEPARTME
8/30/2016 9/2/2016 16 PROFESSIONAL
GOVERNMENT UNITS-CAVITE CLUSTER
TRAINING WORKSHOP ON EXECUTIVE-LEGISLATIVE AGENDA AND CAPACITY DEPARTME
7/28/2016 7/30/2016 24 PROFESSIONAL
DEVELOPMENT AGENDA FORMULATION
COMPETENCY BUILDING PROGRAM FOR PERSONNEL SELECTION BOARD AND CIVIL SERVICE
6/15/2016 6/17/2016 24 SUPERVISORY RESOURCE
PRAISE KEY PLAYERS
WORKSHOP FOR THE SME DEVELOPMENT CONSULTANTS FOR THE THE PREPARATION OF THE TERMS OF REFERENCE FOR THE
INSTITUTIONALIZATION OF THE BUSINESS ADVISORY AND CONSULTANCY SERVICES (I-BACS) IN THE NEGOSYO CENTER 5/23/2016 5/24/2016 16 MANAGERIAL DEPARTME

SEMINAR WORKSHOP ON THE UPDATES ON R.A. 9104 AND ITS REVISED IMPLEMENTING RULES AND REGULATIONS,
PREPARATION OF THE PHILIPPINE BIDDING DOCUMENTS 3/14/2016 3/16/2016 24 PROFESSIONAL BIDS AND

SEMINAR WORKSHOP "MANILA BAY LAW ENFORCEMENT ALLIANCE: REGION IV-A PROVINCIAL
2/18/2013 2/19/2012 16 PROFESSIONAL
CAVITE R
HUMAN RESOURC
SEMINAR ON LEAVE LAWS AND POLICIES 11/26/2015 11/27/2015 16 PROFESSIONAL DEVELO

DEPARTME
ORIENTATION ON THE SETTLEMENT AND RELOCATION ACTION PLANNING (RRAP) 11/17/2015 11/17/2015 8 PROFESSIONAL

BUDGET FORUM ON THE SYNCHRONIZATIONN OF STRATEGIC PERFORMANCE MANAGEMENT SYSTEM AND PROPOSED
BUDGET WITH THE 2016 ANNUAL INVESTMENT PROGRAM 8/19/2015 8/20/2015 16 PROFESSIONAL PROVINCI

TRAINING ON CAPACITY BUILDING AND PRODUCTIVITY DEVELOPMENT 5/22/2015 5/22/2015 8 TEAM HOME HE

SEMINAR WORKSHOP ON WORKPLACE IMPROVEMENT TEAM/ROOT CAUSE

1/23/2014 1/24/2014 16 QUALITY PROVINCI
ANALYSIS AND QMS PLANNING 2014
 ORIENTATION SEMINAR ON COMMUNITY MORTGAGE PROGRAM 3/16/2012 3/16/2012 8 PROFESSIONAL SOCIAL HOU

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

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

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

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

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSH
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

SPORTS N/A INTEGRATE

CAVITE PR
MUSICAL INSTRUMENTS N/A
PUR
N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE CS FORM

PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

N/A

N/A

N/A

N/A

N/A

N/A

N/A
arate sheet if necessary)

OGRAMS ATTENDED
ve (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

LIGHT RAIL MANILA CORPORATION, LIGHT RAIL TRANSIT

AUTHORITY AND ARANETA ENGINEERING SERVICES

CIVIL SERVICE COMMISSION/CAVITE COUNCIL OF HUMAN

RESOURCE MANAGEMENT PRACTITIONERS, INC.

DEPARTMENT OF INTERIOR AND LOCAL

GOVERNMENT
PROVINCIAL COOPERATIVE, LIVELIHOOD AND
ENTREPRENEURIAL DEVELOPMENT OFFICE

PROVINCIAL GOVERNMENT OF CAVITE

DEPARTMENT OF INTERIOR AND LOCAL

GOVERNMENT
DEPARTMENT OF INTERIOR AND LOCAL
GOVERNMENT
CIVIL SERVICE COMMISSION/CAVITE COUNCIL OF HUMAN
RESOURCE MANAGEMENT PRACTITIONERS, INC.

DEPARTMENT OF TRADE AND INDUSTRY

BIDS AND AWARDS COMMITTEE OFFICE

PROVINCIAL ENVIRONMENT AND NATURAL

RESOURCES OFFICE
HUMAN RESOURCE MANAGEMENT OFFICE/PROVINCIAL HOUSIN
DEVELOPMENT AND MANAGEMENT OFFICE

DEPARTMENT OF INTERIOR AND LOCAL

GOVERNMENT

PROVINCIAL GOVERNMENT OF CAVITE

HOME HEALTH EDUCATION SERVICE

PROVINCIAL GOVERNMENT OF CAVITE

 SOCIAL HOUSING FINANCE CORPORATION

N/A

N/A

N/A

N/A

arate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION

(Write in full)

INTEGRATED BAR OF THE PHILIPPINES

CAVITE PROVINCIAL CAPITOL MULTI-
PURPOSE COOPERATIVE
N/A

N/A

N/A

N/A

N/A
arate sheet if necessary)

CS FORM 212 (Revised 2017), Page 2 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 NO
YES ✘
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 phased If YES, give details:
out (abolition) in the public or private sector? ________________________________
RESIGNATION
________________________________
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 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
ATTY. OSCAR S. DELA CRUZ MAKATI CITY (02) 8488234 3.5 cm. X 4.5 cm
(passport size)

JUDGE GONZALO M. MAPILI DASMARIÑAS CITY, CAVITE (046) 4162811 With full and handwritten
name tag and signature over
printed name
TESS ARANETA MANILA CITY 9101111436
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied picture
is not acceptable
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 PHOTO
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 DRIVER'S LICENSE

ID/License/Passport No.: D06-91-082483

Signature (Sign inside the box)

Date/Place of Issuance: 12/27/2017 / CAVITE

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

If YES, give details (country):
, affiant exhibiting his/her validly issued government ID as indicated above.

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