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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.SURNAME LOPEZ
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FIRST NAMEMA. CLEOPATRANAME EXTENSION (JR., SR)
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MIDDLE NAMEAREVALO
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3.DATE OF BIRTH
(mm/dd/yyyy) 		10.25.1980
16. CITIZENSHIP
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4.PLACE OF BIRTHLAPUZ, ILOILO CITYIf holder of dual citizenship, Pls. indicate country:
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5.SEXplease indicate the details.
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6CIVIL STATUS
17. RESIDENTIAL ADDRESS
BLK. 1 LOT 15RAMOS
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House/Block/Lot No.Street
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PETALS VILLE SUBDIVISIONMALIPAYON
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Subdivision/VillageBarangay
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7.HEIGHT (m)1.63 mCABATUANILOILO
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City/MunicipalityProvince
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8.WEIGHT (kg)55 KgsZIP CODE
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9.BLOOD TYPEA+
18. PERMANENT ADDRESS
BLK. 1 LOT 15RAMOS
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House/Block/Lot No.Street
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10.GSIS ID NO.07.7777.7777.PETALS VILLE SUBDIVISIONMALIPAYON
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Subdivision/VillageBarangay
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11.PAG-IBIG ID NO.08.1111.0254.000CABATUANILOILO
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City/MunicipalityProvince
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12.PHILHEALTH NO.027.000.6258.000ZIP CODE 5003
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13.SSS NO.07.2147.256.000
19. TELEPHONE NO.
503.225.546
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14. TIN NO.0123.456.000
20. MOBILE NO.
0920.654.4546
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15. AGENCY EMPLOYEE NO.
062728
21. E-MAIL ADDRESS (if any)
mcalopez@gmail.com
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II. FAMILY BACKGROUND
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22.
SPOUSE'S SURNAME
LOPEZ23. NAME of CHILDREN (Write full name and list all)DATE OF BIRTH (mm/dd/yyyy)
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 FIRST NAMEALEXANDERNAME EXTENSION (JR., SR) IIIVON DAVID A. LOPEZ08.23.2001
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 MIDDLE NAMEESTRADA
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OCCUPATIONSEAFARER
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EMPLOYER/BUSINESS NAME
MAGSAYSAY SHIPPING LINE
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BUSINESS ADDRESSVILLA, AREVALO, ILOILO CITY
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TELEPHONE NO.503.453.221
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24.FATHER'S SURNAMEAREVALO
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FIRST NAMEALFONSONAME EXTENSION (JR., SR)
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MIDDLE NAMEVILLA
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25.MOTHER'S MAIDEN NAME
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SURNAMEAREVALO
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FIRST NAMEMA. ELENA
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MIDDLE NAMEDE LA CRUZ(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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ELEMENTARYCABATUAN CENTRAL ELEM. SCHOOLELEMENTARY198719931993VALEDICTORIAN
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SECONDARYCABATUAN NATIONAL COMPREHENSIVE HIGH SCHOOLHIGH SCHOOL199319971997SALUTATORIAN
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VOCATIONAL / TRADE COURSE
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COLLEGECENTRAL PHILIPPINE UNIVERSITYBACHELOR OF SCIENCE IN SOCIAL WORK199720012001CUM LAUDE
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GRADUATE STUDIES
CENTRAL PHILIPPINE UNIVERSITYMASTER OF SCIENCE IN SOCIAL WORK2007200936 UNITS2009
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(Continue on separate sheet if necessary)
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SIGNATUREDATENOVEMBER 10, 2022
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 CS FORM 212 (Revised 2017), Page 1 of 4
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