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PERSONAL DATA SHEET
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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.
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READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.
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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)
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I. PERSONAL INFORMATION
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2.SURNAMELICOPIT
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FIRST NAMEDIANA GRACENAME EXTENSION (JR., SR) N/A
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MIDDLE NAMECORPUZ
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3.DATE OF BIRTH
(mm/dd/yyyy) 		October 3, 1981
16. CITIZENSHIP
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4.PLACE OF BIRTHBago-Bantay, Quezon CityIf holder of dual citizenship, Pls. indicate country:
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5.SEXplease indicate the details.NA
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6CIVIL STATUS
17. RESIDENTIAL ADDRESS
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House/Block/Lot No.Street
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Subdivision/VillageBarangay
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7.HEIGHT (m)1.54 m
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City/MunicipalityProvince
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8.WEIGHT (kg)58kgZIP CODE
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9.BLOOD TYPEB
18. PERMANENT ADDRESS
40Zone 5
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House/Block/Lot No.Street
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10.GSIS ID NO.2005149538Catayauan
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Subdivision/VillageBarangay
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11.PAG-IBIG ID NO.1340-0074-5044Lallo
Cagayan
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City/MunicipalityProvince
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12.PHILHEALTH NO.06-050058318-8ZIP CODE 3509
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13.SSS NO.01-15355395
19. TELEPHONE NO.
N/A
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14. TIN NO.#ERROR!
20. MOBILE NO.
09758231681
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15. AGENCY EMPLOYEE NO.
R-1135
21. E-MAIL ADDRESS (if any)
dianagracelicopit@csu.edu.ph
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II. FAMILY BACKGROUND
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22.
SPOUSE'S SURNAME
LICOPIT23. NAME of CHILDREN (Write full name and list all)DATE OF BIRTH (mm/dd/yyyy)
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 FIRST NAMEMICHAEL VINCENTNAME EXTENSION (JR., SR) NA AVRIAH LAURENT C. LICOPITJune 4, 2006
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 MIDDLE NAMELIQUIGANALESANDRO ZACH C. LICOPITJuly 16, 2010
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OCCUPATIONN/A
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EMPLOYER/BUSINESS NAME
N/A
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BUSINESS ADDRESSN/A
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TELEPHONE NO.N/A
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24.FATHER'S SURNAMECORPUZ
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FIRST NAMERODOLFONAME EXTENSION (JR., SR) NA
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MIDDLE NAMEUBAY
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MOTHER'S MAIDEN NAME
DUPAYA
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SURNAMECORPUZ
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FIRST NAMEDOLORES
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MIDDLE NAMEMENDEZ(Continue on separate sheet if necessary)
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III. EDUCATIONAL BACKGROUND
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26.LEVELNAME OF SCHOOL (Write in full)BASIC EDUCATION/DEGREE/COURSE (Write in full) PERIOD OF ATTENDANCEHIGHEST LEVEL/ UNITS EARNED
(if not graduated)		YEAR GRADUATED SCHOLARSHIP/ ACADEMIC HONORS RECEIVED
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FromTo
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ELEMENTARYSTO. NIÑO PAROCHIAL SCHOOLPRIMARY EDUCATION19881994N/A1994N/A
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SECONDARYST. PAUL UNIVERSITY, PHILIPPINESHIGHSCHOOL19941998N/A1998N/A
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VOCATIONAL / TRADE COURSENANANANAN/ANAN/A
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COLLEGECENTRO ESCOLAR UNIVERSITYBachelor of Science in TOURISM 19982002N/A2002N/A
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LYCEUM OF APARRIEarning Units in Bachelor of Science in SECONDARY EDUCATION20162017N/A2017N/A
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GRADUATE STUDIES LYCEUM OF APARRIMASTER IN BUSINESS ADMINISTRATION20072009N/A2009N/A
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(Continue on separate sheet if necessary)
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SIGNATUREDATE CS FORM 212 (Revised 2017), Page 1 of 4
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