ROLLY.xlsx - CS Form No 212 Revised 2017 PERSONAL DATA SHEET WARNING Any misinterpretation made in the Personal Data Sheet and the Work Experience Sheet

ROLLY.xlsx - CS Form No 212 Revised 2017 PERSONAL DATA...

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PERSONAL DATA SHEET READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM. 1. CS ID No (Do not fill up. For CSC use only) I. PERSONAL INFORMATION 2. SURNAME GUTIERREZ FIRST NAME ROLLY NAME EXTENSION (JR., SR) MIDDLE NAME SALAS N/A 3. 12/12/1982 16. CITIZENSHIP 4. PLACE OF BIRTH CITY OF SAN FERNANDO, PAMPAN If holder of dual citizenship, Pls. indicate country: 5. SEX please indicate the details. 6 CIVIL STATUS 17. RESIDENTIAL ADDRES 162 BLOCK 8 CUTUD House/Block/Lot No. Street SAN ANTONIO Subdivision/Village Barangay 7. HEIGHT (m) 1.65 M MEXICO PAMPANGA City/Municipality Province 8. WEIGHT (kg) 55 KG ZIP CODE 2021 9. BLOOD TYPE O+ 18. PERMANENT ADDRES 162 BLOCK 8 CUTUD House/Block/Lot No. Street 10. GSIS ID NO. N/A SAN ANTONIO Subdivision/Village Barangay 11. PAG-IBIG ID NO. 9150-1953-3511 MEXICO PAMPANGA City/Municipality Province 12. PHILHEALTH NO. 19-090534402-5 ZIP CODE 2021 13. SSS NO. 02-2050861-2 19. TELEPHONE NO. N/A 14. TIN NO. 229-740-128-000 20. MOBILE NO. 09566851267 15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if a II. FAMILY BACKGROUND 22.SPOUSE'S SURNAME GUTIERREZ FIRST NAME IRENE ARJAY B. GUTIERREZ 03/09/2003 MIDDLE NAME BRAGAIS JASPER B. GUTIERREZ 03/26/2004 OCCUPATION HOUSEWIFE TAMINA IVY B. GUTIERREZ 08/22/2013 EMPLOYER/BUSINESS NAME ZOE B. GUTIRREZ 5/26/2016 BUSINESS ADDRESS TELEPHONE NO. 24.FATHER'S SURNAME GUTIERREZ FIRST NAME ROBERTO MIDDLE NAME MICLAT 25.MOTHER'S MAIDEN NAME SURNAME SALAS FIRST NAME LYDIA MIDDLE NAME ONOFRE (Continue on separate sheet if necessary) III. EDUCATIONAL BACKGROUND 26. LEVEL From To ELEMENTARY PRIMARY 1991 1996 1996 NONE SECONDARY SAINT'S JOSEPH ACADEMY SECONDARY 1996 2000 2000 NONE N/A COLLEGE N/A GRADUATE STUDIES N/A (Continue on separate sheet if necessary) SIGNATURE DATE CS FORM 212 (Revised 2017), Page 1 of 4 WARNING: Any misinterpretation made in the Personal Data Sheet and the Work Experience Sheet shall cause the filing of administrative/criminal case/s against the person concerned.
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