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 MADLAMBAYAN
FIRST NAME MARK NOEL NAME EXTENSION (JR., SR) N/A
MIDDLE NAME GERVACIO
3. DATE OF BIRTH
(mm/dd/yyyy) 12/31/1985 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH Tarlac, Tarlac City If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female
17. RESIDENTIAL ADDRESS
6 CIVIL STATUS Single ✘ Married
House/Block/Lot No. Street
Widowed ✘ Separated
Magaspac
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 170cm Gerona Tarlac
City/Municipality Province
8. WEIGHT (kg) 70 ZIP CODE 2302
18. PERMANENT ADDRESS
9. BLOOD TYPE A+
House/Block/Lot No. Street
10. GSIS ID NO. N/A Balaoang
Subdivision/Village Barangay
11. PAG-IBIG ID NO. 121030462498 Paniqui Tarlac
City/Municipality Province
12. PHILHEALTH NO. N/A ZIP CODE 2307
13. SSS NO. 228142787 19. TELEPHONE NO.
14. TIN NO. 415786397 20. MOBILE NO. 09457642227
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) mnmadlambayan031@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME Madlambayan 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) KYLE XANDER MADLAMBAYAN
FIRST NAME Carla 9/17/2013
MIDDLE NAME Doctolera KEITH XENO MADLAMBAYAN 11/10/2018
OCCUPATION Bank Teller
EMPLOYER/BUSINESS NAME Eastwest Bank
BUSINESS ADDRESS Paniqui, Tarlac
TELEPHONE NO. 045 4910590
24. FATHER'S SURNAME Madlambayan
NAME EXTENSION (JR., SR)
FIRST NAME Francisco
MIDDLE NAME Punzalan
25. MOTHER'S MAIDEN NAME
SURNAME Gervacio
FIRST NAME Aida
MIDDLE NAME Gungap (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
NAME OF SCHOOL HIGHEST LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
BASIC EDUCATION/DEGREE/COURSE UNITS ACADEMIC
LEVEL (Write in EARNED
GRADUATED
HONORS
(Write in full)
full) (if not graduated) RECEIVED
NAME OF SCHOOL HIGHEST LEVEL/ SCHOLARSHIP/
YEAR
BASIC EDUCATION/DEGREE/COURSE UNITS ACADEMIC
LEVEL (Write in EARNED
GRADUATED
HONORS
(Write in full)
full) (if not graduated) RECEIVED
From To
ELEMENTARY St. Rose Catholic School Elementary 1992 1998 Graduated N/A
SECONDARY
VOCATIONAL / St. Rose Catholic School High School 1998 2002 Graduated N/A
N/A N/A
TRADE
2002 2007
COURSE
COLLEGE Pines City Colleges Bachelor of Science in Nursing Graduated N/A
GRADUATE STUDIES
(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
Licensure Examination for Nursing 75% 7/16/2019 Baguio City 0803558 12/31/2019
(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)
7/1/2019 Present Staff Nurse Tarlac Provincial Hospital 14542.00 N/A Job Order N
4/1/2019 6/30/2019 Staff Nurse Tarlac Provincial Hospital 9409.97 N/A Job Order N
10/30/2015 12/15/2017 Staff Nurse Male Comprehensive Rehabilitation Center 40000.00 N/A Contractual N
2/3/2014 10/20/2015 Staff Nurse Talon General Hospital 12000.00 N/A Permanent 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 POSITION / NATURE OF WORK
From To
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
Basic Life Support 12/6/2013 12/6/2013 8.0 Technical Institute For Nursing Enrichment Training Center
Advance Cardioascular Life Support 12/6/2013 12/6/2013 8.0 Technical Institute For Nursing Enrichment Training Center
Institute For Nursing Enrichment Training Center
ECG Reading 12/6/2013 12/6/2013 8.0 Technical
Basic Emergency Cardiovascular Pharmacology 12/6/2013 12/6/2013 8.0 Technical
Institute For Nursing Enrichment Training Center
Regular IV Training Program 7/25/2013 7/27/2013 8.0 Technical
Institute For Nursing Enrichment Training Center
(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)
Swimming N/A N/A
Basketball N/A N/A
Cooking N/A 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 ✘
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘
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? ________________________________
________________________________
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
Warren Sarsagat Paniqui Tarlac 9989613002 3.5 cm. X 4.5 cm
(passport size)
Macross Bala Camiling Tarlac 459825416 With full and handwritten
name tag and signature over
printed name
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 (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.: 0803558
Signature (Sign inside the box)
Date/Place of Issuance: 7/16/2013
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
