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 ag
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

I. PERSONAL INFORMATION
2. SURNAME JACINTO
NAME EXTENSION (JR., SR
FIRST NAME NELLEN

MIDDLE NAME BIONSON

3. DATE OF BIRTH
(mm/dd/yyyy) 10/14/1973 16. CITIZENSHIP
✘ Filipino Dual Citizenship
✘ by birth b
4. PLACE OF BIRTH MALAYBALAY, BUKIDNON If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male ✘ Female

Single ✘ Married 17. RESIDENTIAL ADDRESS PUROK 4 LUNSAY

6 CIVIL STATUS
House/Block/Lot No. S
Widowed Separated
SUM
Other/s:
Subdivision/Village Ba
MALAYBALAY CITY BUK
7. HEIGHT (m) 154m
City/Municipality Pr
8. WEIGHT (kg) 57.8 kg ZIP CODE 8700

18. PERMANENT ADDRESS PUROK 4 LUNSAY

9. BLOOD TYPE "B"
House/Block/Lot No. S
SUM
10. GSIS ID NO. N/A
Subdivision/Village Ba
MALAYBALAY CITY
11. PAG-IBIG ID NO. 1820-0015-3940
City/Municipality Pr

12. PHILHEALTH NO. 15-200920741-9 ZIP CODE 8

13. SSS NO. 08-1360357-1 19. TELEPHONE NO. N/A

14. TIN NO. 926-396-124 20. MOBILE NO. 09175553766

15. AGENCY EMPLOYEE NO. 01-806 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME JACINTO 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) LAURA KATRINA B. JACINTO
FIRST NAME DELFIN

MIDDLE NAME TICO PATRICK JAMES B. JACINTO

OCCUPATION BUSINESSMAN

EMPLOYER/BUSINESS NAME JACINTO STORE

BUSINESS ADDRESS CAWAYAN, LANTAPAN, BUKIDNON

TELEPHONE NO. 9173015560

24. FATHER'S SURNAME BIONSON

NAME EXTENSION (JR., SR)
FIRST NAME NELSON
 MIDDLE NAME B.

25. MOTHER'S MAIDEN NAME

SURNAME PATRIARCA

FIRST NAME LUISITA

MIDDLE NAME PACNIS (Continue on separate sheet if necessary

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL HIGHEST LEVEL/
26. BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE UNITS
LEVEL (Write in EARNED
(Write in full)
full) (if not graduated)
From To

ELEMENTARY SUMPONG ELEMENTARY SCHOOL ELEMENTARY GRADUATE N/A N/A GRADUATED

SECONDARY /
VOCATIONAL BUKIDNON NATIONAL HIGH SCHOOL HIGH SCHOOL GRADUATE N/A N/A GRADUATED

CAGAYAN CAPITOL COLLEGE MIDWIFERY N/A N/A GRADUATED

TRADE
COURSE BACHELOR OF SCIENCE IN NURSING
COLLEGE MEDINA COLLEGE N/A N/A GRADUATED

GRADUATE STUDIES N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE March

CS FORM
L DATA SHEET
erience Sheet shall cause the filing of administrative/criminal case/s against the person

EFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Dual Citizenship

by naturalization
Pls. indicate country:

LUNSAYAN STREET
Street
SUMPONG
Barangay
BUKIDNON
Province
8700

LUNSAYAN STREET
Street
SUMPONG
Barangay
BUKIDNON
Province

8700

N/A

09175553766

[email protected]

DATE OF BIRTH (mm/dd/yyyy)

9/23/2003

6/16/2008
 (Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

1986 N/A

1990 N/A

1993 N/A

2001 N/A

N/A N/A
parate sheet if necessary)

March 19, 2018

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 ap
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

MIDWIFERY LICENSE 4/30 & 5/1/1994 METRO MANILA 0119293

(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.
28. INCLUSIVE DATES SALARY/ JOB/ PAY
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

UP TO
1/19/2001 PRESENT MIDWIFE CITY HEALTH OFFICE 11606.20 N/A JOB ORDER
 (Continue on separate sheet if necessary)

SIGNATURE DATE MARCH 19, 2018

CS FORM 212 (Revised 20

 LICENSE (if applicable)

Date of
Validity

10/14/2020

arate sheet if necessary)

GOV'T
SERVICE

(Y/
N)
Y
arate sheet if necessary)

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 /
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/ CONDUCTED/
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To

TRAINING ON VISUAL INSPECTION WITH ACETIC ACID 11/26/2010 11/26/2010 8 HOURS LGU MA

TRAINING ON NEWBORN SCREENING PROGRAM 4/16/2010 4/17/2010 16 HOURS

LGU MA

DIABETIC EDUCATION TRAINING 4/23/2009 4/24/2009 16 HOURS

LGU

COMMUNITY MANAGE MATERNAL AND NEWBORN CARE 1/28/2009 1/29/2009 16 HOURS

LGU MA

STRATEGIC PLANNING WORKSHOP ON R.A.9003 ECOLOGICAL MANAGEMENT 12/2/2008 12/2/2008 8 HOURS

LGU MA
FILED HEALTH SERVICES INFORMATION SYSTEM (FHSIS) VERSION 2008
8/18/2008 8/18/2008 8 HOURS
TRAINING LGU MA
ORIENTATION ON THE REVISED MANUAL OF PROCEDURES FOR THE NATIONAL
5/8/2008 5/9/2008 16 HOURS
TUBERCULOSIS CONTROL PROGRAM FOR RURAL HEALTH MIDWIVES LGU MA

BOTICA NG BARANGAY MANAGEMENT SEMINAR 2/21/2008 2/22/2008 16 HOURS

LGU

PHILIPPINE CLINICAL STANDARDS MANUAL FOR FAMILY PLANNING 11/21/2007 11/23/2007 24 HOURS LGU MALAY

QUALITY MIDWIFERY CARE THROUGH ADVANCES IN TECHNOLOGIES 10/18/2005 10/21/2005 32 HOURS LGU MA

MIDWIVES ENRICHMENT SEMINAR 1/24/2004 1/24/2004 8 HOURS

DISASTER MANAGEMENT TRAINING OF
BARANGAY DISASTER COORDINATING 6/26/2004 6/27/2004 16 HOURS
COUNCILS LGU

EPI BASIC SKILLS TRAINING 11/10/2003 11/14/2003 40 HOURS

PARTOGRAPH TRAINING 11/5/2002 11/7/2002 24 HOURS

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERS
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)
 (Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

N/A

eparate sheet if necessary)

ROGRAMS ATTENDED
five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

LGU MALAYBALAY

LGU MALAYBALAY

MALAYBALAY

LGU MALAYBALAY

LGU MALAYBALAY

LGU MALAYBALAY

LGU MALAYBALAY

MALAYBALAY

LGU MALAYBALAY

LGU MALAYBALAY

PLGMI

MALAYBALAY

LGU MALAYBALAY

LGU MALAYBALAY

eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)
eparate sheet if necessary)

MARCH 19, 2018

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, YES
✘ NO

✘ NO
a. within the third degree? YES
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? ✘ NO
YES
If YES, give details:
________________________________
________________________________
✘ NO
YES
b. Have you been criminally charged before any court?
If YES, give details:
✘ NO ________________________________
Date Filed:
YES
________________________________
Status of Case/s:
✘ NO
36. Have you ever been convicted of any crime or violation of any law, decree,
YESordinance or regulation
by any court or tribunal?
YE ✘ NO If YES, give details:
S ________________________________
✘ NO
________________________________
37. YES resignation,
Have you ever been separated from the service in any of the following modes:
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
✘ NO (except
YES
Barangay election)?
NO If YES, give details:
YES
b. Have you resigned from the government service during the three (3)-month period before
NO the last
election to promote/actively campaign for a national or local candidate? YES If YES, give details:
39. Have you acquired the status of an immigrant or permanent resident of another country?
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?
If YES, please specify:
b. Are you a person with disability?
If YES, please specify ID No:
c. Are you a solo parent?
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
ROBERTO M. SOLITO SUMPONG, MALAYBALAY CITY 9269994902 4.5 cm. X 3.5 cm
(passport size)

DR. MELIROSE S. DETECIO MALAYBALAY CITY 9177189004

Computer generated
or photocopied picture
LYZANDER CEDRIC D. MAANDIG MALAYBALAY CITY 9355881855 is not acceptable

42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and
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 LICENSE

ID/License/Passport No.: 0119293

Signature (Sign inside the box)
MARCH 19, 2018
Date/Place of Issuance: CAGAYAN DE ORO CITY
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 o

If YES, give details (country):
, affiant exhibiting his/her validly issued government ID as indicated above.

CS FORM 212 (Revised 2017), Page 4 of 4