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 RAWTHER
NAME EXTENSION (JR., SR) N/A
FIRST NAME AHMED SAMEER

MIDDLE NAME KAIDAL

3. DATE OF BIRTH
(mm/dd/yyyy) 11/8/1999 16. CITIZENSHIP
✘

4. PLACE OF BIRTH ZAMBOANGA CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘

17. RESIDENTIAL ADDRESS 0155 CAMIAS

6 CIVIL STATUS ✘
House/Block/Lot No. Street
N/A BUS-BUS
Subdivision/Village Barangay
JOLO SULU
7. HEIGHT (m) 1.676
City/Municipality Province
8. WEIGHT (kg) 60 ZIP CODE 7400

18. PERMANENT ADDRESS 0155 CAMIAS

9. BLOOD TYPE B+
House/Block/Lot No. Street
N/A BUS-BUS
10. GSIS ID NO. N/A
Subdivision/Village Barangay
JOLO SULU
11. PAG-IBIG ID NO. N/A
City/Municipality Province

12. PHILHEALTH NO. 200251258588 ZIP CODE 7400

13. SSS NO. 10-1396889-5 19. TELEPHONE NO. N/A

14. TIN NO. 610-994-736 20. MOBILE NO. 0915733374

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) N/A
FIRST NAME N/A N/A N/A

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME RAWTHER

NAME EXTENSION (JR., SR) N/A
FIRST NAME REJI

MIDDLE NAME IBRAHIM

25. MOTHER'S MAIDEN NAME

SURNAME KAIDAL

FIRST NAME FATMA

MIDDLE NAME DAIS (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
(Write in full) HONORS
full) (if not graduated) RECEIVED
From To

ELEMENTARY MOHAMMAD TULAWIE CENTRAL SCHOOL PRIMARY EDUCATION 2006 2012 GRADUATED 2012 N/A

SECONDARY /
VOCATIONAL NOTRE DAME OF JOLO HIGH SCHOOL - KASULUTAN SECONDARY EDUCATION 2012 2016 GRADUATED 2016 N/A

NOTRE DAME OF JOLO COLLEGE- SENIOR HIGH HE -BARTENDING, TOURISM PROMOTION, WITH
SCHOOL FOOD AND BEVERAGE SERVICES
2016 2018 GRADUATED 2018
HONORS
TRADE
COURSE
COLLEGE NOTRE DAME OF JOLO COLLEGE BACHELOR OF SCIENCE IN NURSING 2018 2022 GRADUATED 2022 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 MARCH 25,2024

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

R.A 1080 (NURSING LICENSURE EXAMINATION) 82.40% 05/29-30/2022 ZAMBOANGA CITY 0939325 11/28/2025

(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 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)

0101/2024 PRESENT NURSE IPHO- SULU PROVINCIAL HOSPITAL 10,000.00 N/A JOB ORDER N

4/1/2023 6/30/2023 NURSE IPHO- SULU PROVINCIAL HOSPITAL 5,000.00 N/A JOB ORDER N

(Continue on separate sheet if necessary)

SIGNATURE DATE MARCH 25,2024

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

INTEGRATED PUBLIC HEALTH OFFICE - SULU PROVINCIAL HOSPITAL 6/1/2023 12/31/2023 1088 HOURS NURSE

INTEGRATED PUBLIC HEALTH OFFICE - SULU PROVINCIAL HOSPITAL 2/1/2023 3/31/2023 345 HOURRS NURSE

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
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

HIV AWARENESS 7/8/2023 7/8/2023 1.5 TECHNICAL SULU MEDICAL SOCIETY

INFECTION CONTROL STEWARDSHIP 7/8/2023 7/8/2023 1.5 TECHNICAL SULU MEDICAL SOCIETY

(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
(Write in full)
in full)

READING N/A N/A

COOKING

(Continue on separate sheet if necessary)

SIGNATURE DATE MARCH 25,2024

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? ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? ✘

If YES, give details:

________________________________

35. a. Have you ever been found guilty of any administrative offense? ✘

If YES, give details:

________________________________
________________________________
b. Have you been criminally charged before any court? ✘

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
✘
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, ✘
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 ✘
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last ✘
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?
✘

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
INTEGRATED PROVINCIAL HEALTH the last 6 months
MUSDARI T. HARADJI, RN OFFICE SULU PROVINCIAL HOSPITAL
9175458083 4.5 cm. X 3.5 cm
(passport size)
INTEGRATED PROVINCIAL HEALTH
FAIZAL P. SAPPAL, RN OFFICE SULU PROVINCIAL HOSPITAL
9268079783
Computer generated
INTEGRATED PROVINCIAL HEALTH or photocopied picture
REYNALDO Q. PESCADERA III, MD OFFICE SULU PROVINCIAL HOSPITAL
9173219041 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

ID/License/Passport No.: 0939325

Signature (Sign inside the box)
MARCH 25,2024
Date/Place of Issuance: 07/15/2022 ZAMBOANGA 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 of 4