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 GARCIA
FIRST NAME ROSE ANN NAME EXTENSION (JR., SR) N/A
MIDDLE NAME TOLENTINO
3. DATE OF BIRTH
11/30/1989 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH LLANERA, NUEVA ECIJA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female
6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS PUROK 3
House/Block/Lot No. Street
Separat
Widowed GEN. LUNA
Other/s: ed Subdivision/Village Barangay
LLANERA NUEVA ECIJA
7. HEIGHT (m) 1.62
City/Municipality Province
8. WEIGHT (kg) 72kg. ZIP CODE 3126
18. PERMANENT ADDRESS PUROK 3
9. BLOOD TYPE 0+
House/Block/Lot No. Street
GEN. LUNA
10. GSIS ID NO. N/A
Subdivision/Village Barangay
LLANERA NUEVA ECIJA
11. PAG-IBIG ID NO.
City/Municipality Province
12. PHILHEALTH NO. 210000184300 ZIP CODE 3126
13. SSS NO. 02-4525200-8 19. TELEPHONE NO. N/A
14. TIN NO. 445-541-180-000 20. MOBILE NO. 0905-858-4321
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) roseann_nov30@yahoo.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME GARCIA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME NHEIL JAKE N/A N/A N/A
MIDDLE NAME AGAPITO
OCCUPATION MEDICAL TECHNOLOGIST I
EMPLOYER/BUSINESS NAME M.V. GALLEGO CABANATUAN CITY GENERAL HOSPITAL
BUSINESS ADDRESS CABANATUAN CITY, NUEVA ECIJA
TELEPHONE NO. N/A
24. FATHER'S SURNAME TOLENTINO
FIRST NAME MAURO
MIDDLE NAME RAMOS
25. MOTHER'S MAIDEN NAME
SURNAME MALLARE
FIRST NAME ESMERALDA
MIDDLE NAME MEND0ZA (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 ACADEMIC
LEVEL (Write in EARNED GRADUATED HONORS
(Write in full)
full) (if not graduated) RECEIVED
From To
ELEMENTARY GEN.LUNA ELEMENTARY SCHOOL PRIMARY 1995 2001 GRADUATED 2001 N/A
SECONDARY /
VOCATIONAL GEN. LUNA NATIONAL HIGH SCHOOL SECONDARY 2001 2005 GRADUATED 2005 N/A
N/A N/A N/A N/A N/A N/A N/A
TRADE
NUEVA ECIJA UNIVERSITY OF SCIENCE AND
COURSE
COLLEGE
TECHNOLOGY
BACHELOR OF SCIENCE IN NURSING 2007 2011 GRADUATED 2011 N/A
GRADUATE STUDIES 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 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
NURSE LICENSURE EXAMINATION 80.00% 07/02-03/2011 U.E CM RECTO, MANILA 0713751 11/30/2020
(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
SERVICE
28. INCLUSIVE DATES SALARY/ JOB/ PAY
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY GRADE (if applicable)& STATUS OF
(Write in full/Do not (Write in SALARY STEP (Format "00-0")/ APPOINTMENT
abbreviate) full/Do not abbreviate) INCREMENT
From To (Y/
N)
DEPARTMENT OF HEALTH CENTRAL LUZON
06/17/2019 PRESENT NURSE II-PHA CENTER FOR HEALTH DEVELOPMENT
32, 057 15-1 JOB ORDER N
01/15/2018 12/31/2018 NURSE II DEPARTMENT OF HEATH REGIONAL OFFICE 3 31, 765 15-1 JOB ORDER N
01/15/2016 12/31/2017 NURSE II DEPARTMENT OF HEATH REGIONAL OFFICE 3 26, 878 15-1 JOB ORDER N
01/15/2014 12/31/2015 NURSE I DEPARTMENT OF HEATH REGIONAL OFFICE 3 18, 549 15-1 JOB ORDER N
(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
From To
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/
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To
BASIC LIFE SUPPORT TRAINING 09/16/2016 09/17/2016 16.0 N/A
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32.
(Write in full)
LANGUAGE: FILIPINO, ENGLISH N/A
COMPUTER RELATED SKILLS: MS WORD, EXCEL,
POWERPOINT
COOKING
GARDENING
READING BOOKS
(Continue on separate sheet if necessary)
SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S
POSITION / NATURE OF WORK
N/A
e on separate sheet if necessary)
ROGRAMS ATTENDED
t five (5) years for Division Chief/Executive/Managerial positions)
CONDUCTED/ SPONSORED BY
(Write in full)
DR. PJGMRMC
e on separate sheet if necessary)
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in full)
N/A
e on separate sheet if necessary)
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:
________________________________
35. a. Have you ever been found guilty of any administrative offense? YES ✘ NO
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court? YES ✘ NO
If YES, give details:
________________________________
Date Filed:
________________________________
Status of Case/s:
36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation
YES ✘ NO
by any court or tribunal?
If YES, give details:
________________________________
________________________________
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? FINISHED CONTRACT
________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except YES ✘ NO
Barangay election)?
If YES, give details:
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:
39. Have you acquired the status of an immigrant or permanent resident of another country?
YES ✘ NO
If YES, give details (country):
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:
b. Are you a person with disability? YES ✘ NO
If YES, please specify ID No:
c. Are you a solo parent? YES ✘ NO
If YES, please specify ID No:
41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)
NAME ADDRESS TEL. NO.
ID picture taken within
the last 6 months
JULIETA M. BERNARDO, RN, MAN SAN RICARDO TALAVERA, NE 0942-311-9435 3.5 cm. X 4.5 cm
(passport size)
CYNTHIA C. GARCIA, RN LLANERA, NUEVA ECIJA 0965-227-3707 With full and handwritten
name tag and signature over
printed name
TEOFILA B. BULOSAN STA. BARBARA, LLANERA, NE 0923-886-3992
Computer generated
42. or photocopied picture
I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and 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 (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)
PLEASE INDICATE ID Number and Date of
Issuance
Government Issued ID: PRC
ID/License/Passport No.: 0713751
Signature (Sign inside the box)
Date/Place of Issuance: 09/15/2011/MANILA
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
