Page 1787 - AACCUP Accreditation_AreaIV

CS Form No. 212
PERSONAL DATA SHEET
Revised 2017

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 LORENZO
N/A
FIRST NAME JIZABELLE
MIDDLE NAME PATTALITAN
3. DATE OF BIRTH
(mm/dd/yyyy) 03/08/1989 16. CITIZENSHIP Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH ANGADANAN, ISABELA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female
Single Married 17. RESIDENTIAL ADDRESS
6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
Other/s: ALLANGIGAN
Subdivision/Village Barangay
7. HEIGHT (m) 1.57 ANGADANAN ISABELA
City/Municipality Province
8. WEIGHT (kg) 53.5 ZIP CODE 3311
9. BLOOD TYPE O+ 18. PERMANENT ADDRESS
House/Block/Lot No. Street
10. GSIS ID NO. 2005-262-838 ALLANGIGAN
Subdivision/Village Barangay
11. PAG-IBIG ID NO. 121064119873 ANGADANAN ISABELA
City/Municipality Province
12. PHILHEALTH NO. 06-20062215-78 ZIP CODE 3307
13. SSS NO. 19-1979782-2 19. TELEPHONE NO. N/A

14. TIN NO. 285-588-247 20. MOBILE NO. 09361328630
15. AGENCY EMPLOYEE NO. JPL-030889 21. E-MAIL ADDRESS (if any) pattalitanjizabelle@yahoo.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME LORENZO 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
FIRST NAME JOHN TIMOTHY N/A LORENZO, JOHN JARED PATTALITAN 09/02/2014
MIDDLE NAME DANUGAN LORENZO, JETHRO ZANE PATTALITAN 08/31/2016
OCCUPATION N/A LORENZO, JAMESON HANS PATTALITAN 10/10/2017
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME PATTALITAN

FIRST NAME ALMOR N/A
MIDDLE NAME SINGUN
25. MOTHER'S MAIDEN NAME
SURNAME ALIANGAN
FIRST NAME DELIA
MIDDLE NAME LAYUGAN (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
SCHOLARSHIP/
HIGHEST LEVEL/
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE YEAR ACADEMIC
PERIOD OF ATTENDANCE

LEVEL UNITS EARNED
(Write in full) (Write in full) (if not graduated) GRADUATED HONORS
From To RECEIVED
ELEMENTARY SCHOOL OF OUR LADY OF ATOCHA ELEMENTARY 1995 2001 N/A 2001 N/A
SECONDARY SCHOOL OF OUR LADY OF ATOCHA HIGH SCHOOL 2001 2005 N/A 2005 N/A
VOCATIONAL / N/A N/A N/A N/A N/A
N/A
N/A
TRADE COURSE
COLLEGE UNIVERSITY OF LA SALETTE, INC. BACHELOR OF SCIENCE IN PSYCHOLOGY 2005 2009 N/A 2009 N/A
MASTER OF ARTS IN GUIDANCE AND
GRADUATE STUDIES UNIVERSITY OF LA SALETTE, INC. 2009 2011 N/A 2011 N/A
COUNSELING
(Continue on separate sheet if necessary)
SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 1 of 4