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 LEE
NAME EXTENSION (JR., SR) N/A
FIRST NAME ADRIAN CHRISTIAN

MIDDLE NAME NUA

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 09/23/1995 ✘ Filipino Dual Citizenship
by
✘ by birth
4. PLACE OF BIRTH TONDO, MANILA If holder of dual citizenship, Pls. indicate country:naturalization
please indicate the details.
5. SEX ✘ Male Female
Single 17. RESIDENTIAL ADDRESS 40-I GEMPESAW STREET
6 CIVIL STATUS ✘ Married
House/Block/Lot No. Street
Widowed Separat BRGY. 26 - C
Other/s: ed Subdivision/Village Barangay

7. HEIGHT (m) 1.7 DAVAO CITY DAVAO DEL SUR

City/Municipality Province
8. WEIGHT (kg) 75 ZIP CODE 8000

9. BLOOD TYPE O+
18. PERMANENT ADDRESS 40-I GEMPESAW STREET
House/Block/Lot No. Street

10. GSIS ID NO. BRGY. 26 - C

Subdivision/Village Barangay

11. PAG-IBIG ID NO.

DAVAO CITY DAVAO DEL SUR
City/Municipality Province

12. PHILHEALTH NO. ZIP CODE 8000

13. SSS NO. 19. TELEPHONE NO. N/A

14. TIN NO. 20. MOBILE NO. 09663889046

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) adrianchristianlee@[Link]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME N/A

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME LEE

NAME EXTENSION (JR., SR)
FIRST NAME CHARLY N/A

MIDDLE NAME SHE

25. MOTHER'S MAIDEN NAME

SURNAME NUA

FIRST NAME AUDREY

MIDDLE NAME COCAM (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY DAVAO CHONG HUA HIGH SCHOOL ELEMENTARY 2002 2008 N/A 2008 N/A

SECONDARY DAVAO CHONG HUA HIGH SCHOOL SECONDARY 2008 2012 N/A 2012 N/A

VOCATIONAL/ TRADE
COURSE N/A

BACHELOR OF SCIENCE IN CIVIL

COLLEGE ATENEO DE DAVAO UNIVERSITY 2012 2017 N/A 2017 N/A
ENGINEERING

GRADUATE STUDIES N/A

(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 DATE OF LICENSE (if applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity

CSC WATER RESOURCES FACILITIES OPERATOR PASSED 09/09/2020 CSC REGIONAL OFFICE - XI 360111200011 N/A

(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
28. INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)
SENIOR WATER RESOURCES FACILITIES
09/09/2020 PRESENT DAVAO CITY WATER DISTRICT P20,219.00 10-1 PERMANENT Y
OPERATOR A
SENIOR WATER RESOURCES FACILITIES
07/12/2020 09/08/2020 DAVAO CITY WATER DISTRICT P20,219.00 10-1 TEMPORARY Y
OPERATOR A
SENIOR WATER RESOURCES FACILITIES
01/01/2020 07/11/2020 DAVAO CITY WATER DISTRICT P19,233.00 10-1 TEMPORARY Y
OPERATOR A
SENIOR WATER RESOURCES FACILITIES
07/12/2019 12/31/2019 DAVAO CITY WATER DISTRICT P19,233.00 10-1 TEMPORARY Y
OPERATOR A
JOB ORDER
01/01/2019 07/11/2019 WATER RESOURCES FACILITIES OPERATOR B DAVAO CITY WATER DISTRICT P9,768.00 N/A N
CONTRACT
JOB ORDER
07/01/2016 12/31/2018 WATER RESOURCES FACILITIES OPERATOR B DAVAO CITY WATER DISTRICT P8,888.00 N/A N
CONTRACT
JOB ORDER
08/19/2015 06/30/2016 WATER RESOURCES FACILITIES OPERATOR B DAVAO CITY WATER DISTRICT P7,414.00 N/A N
CONTRACT

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 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 / NATURE OF WORK
From To

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

(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/ SPONSORED BY
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

WATER RESOURCES FACILITIES OPERATORS COURSE 02/18/2020 02/20/2020 24 TECHNICAL DAVAO CITY WATER DISTRICT

PRESENTATION OF DCWD'S 2018-2023 MEDIUM-TERM DEVELOPMENT PLAN

09/20/2019 09/20/2019 4 TECHNICAL DAVAO CITY WATER DISTRICT
(MTDP)

BUILDING COMMON GROUND PHASE 1 FOR PERMANENT EMPLOYEES 09/06/2019 09/06/2019 8 FOUNDATION DAVAO CITY WATER DISTRICT

WATER SAFETY PLAN ORIENTATION 7/10/2019 07/10/2019 8 TECHNICAL DAVAO CITY WATER DISTRICT

DELIVERING EXCELLENT SERVICE THROUGH PERSONALITY ENHANCEMENT

03/21/2017 03/21/2017 4 FOUNDATION DAVAO CITY WATER DISTRICT
WITH GOOD GROOMING AND PERSONAL HYGIENE

WATER SAFETY PLAN ORIENTATION 03/21/2017 03/21/2017 4 TECHNICAL DAVAO CITY WATER DISTRICT

BASIC WATER UTILITY OPERATIONS 06/30/2016 06/30/2016 8 TECHNICAL DAVAO CITY WATER DISTRICT

PUMP OPERATION AND MAINTENANCE SEMINAR 11/27/2015 11/27/2015 8 TECHNICAL DAVAO CITY WATER DISTRICT

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

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33. (Write in
(Write in full)
full)

BILLIARDS N/A N/A

BASKETBALL

SWIMMING

N/A

(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:
________________________________
N/A
________________________________
35. a. Have you ever been found guilty of any administrative offense?
YES ✘ NO
If YES, give details:
________________________________
N/A
________________________________
b. Have you been criminally charged before any court? YES ✘ NO
If YES, give details:
________________________________
Date Filed: N/A
________________________________
Status of Case/s: N/A

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:
________________________________
N/A
________________________________
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? ________________________________
N/A
________________________________
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: N/A

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: N/A
39. Have you acquired the status of an immigrant or permanent resident of another country?
YES ✘ NO
If YES, give details (country):
N/A
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: N/A
b. Are you a person with disability? YES ✘ NO
If YES, please specify ID No: N/A
c. Are you a solo parent? YES ✘ NO
If YES, please specify ID No: N/A

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
ENG'R. AMAURE A. DALISAY c/o DAVAO CITY WATER DISTRICT 235-3293 3.5 cm. X 4.5 cm
(passport size)

ENG'R. REJAN V. ZERNA c/o DAVAO CITY WATER DISTRICT 235-3293 With full and handwritten
name tag and signature over
printed name
ENG'R. RENANTE S. ANDAL c/o DAVAO CITY WATER DISTRICT 235-3293
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 ([Link], GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of
Issuance
Government Issued ID: DAVAO CITY WATER DISTRICT
ID/License/Passport No.: 001665 Signature (Sign inside the box)

Date/Place of Issuance: 08/19/2015, DAVAO CITY

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