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 H.GAFOR

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

MIDDLE NAME SULTAN

3. DATE OF BIRTH
(mm/dd/yyyy) 2/18/1993 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH BINIDAYAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS N/A N/A

Widowed Separated House/Block/Lot No. Street
BARIO GREEN
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 1.52 M MARAWI CITY LANAO DEL SUR
City/Municipality Province
8. WEIGHT (kg) 62 KG ZIP CODE 9700

9. BLOOD TYPE "O" POSITIVE

18. PERMANENT ADDRESS N/A N/A
House/Block/Lot No. Street
10. GSIS ID NO. N/A N/A POBLACION
Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A BINIDAYAN LANAO DEL SUR

City/Municipality Province

12. PHILHEALTH NO. 20-025101286-4 ZIP CODE 9310

13. SSS NO. N/A 19. TELEPHONE NO. N/A

14. TIN NO. 768-369897-000 20. MOBILE NO. 0970-373-8846/0955-032-2126

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME ALIODEN 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) ABDELHAY ASHARY
FIRST NAME ASHARY N/A 6/8/2021

MIDDLE NAME ADIONG AARIZ ASHARY 04/31/2024

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME MULOK

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

MIDDLE NAME DEGAID

25. MOTHER'S MAIDEN NAME H.RASMIA SULTAN MULOK

SURNAME SULTAN

FIRST NAME H.RASMIA

MIDDLE NAME SHARIEF (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
From To

DIMAPORO CENTRAL ELEMTARY

ELEMENTARY ELEMENTARY 2001 2007 GRADUATED 2007 NONE
SCHOOL

SECONDARY /
VOCATIONAL MSU BINIDAYAN HIGH SCHOOL 2007 2011 GRADUATED 2011 NONE

N/A N/A N/A N/A N/A N/A N/A

TRADE
ADVENTIST MEDICAL BACHELOR OF SCIENCE IN MEDICAL
COURSE
COLLEGE
CENTER COLLEGE 2014 2018 GRADUATED 2018 NONE
TECHNOLOGY

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

(Continue on separate sheet if necessary)

SIGNATURE DATE January 1, 2024

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

PRC LICENSE 77% 3/13-14/2019 MANILA 0094378 02/18/2025

(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
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)

1/1/2024 6/30/2024 JOB ORDER MEDTECH AMAI PAKPAK MEDICAL CENTER 21,494 11 JOB ORDER Y

1/1/2023 12/31/2023 HRH MEDTECH AMAI PAKPAK MEDICAL CENTER 33000 N/A JOB ORDER Y

1/1/2022 12/31/2022 HRH MEDTECH AMAI PAKPAK MEDICAL CENTER 41000 15 JOB ORDER Y

10/15/2021 12/31/2021 HRH MEDTECH AMAI PAKPAK MEDICAL CENTER 41000 15 JOB ORDER Y

6/1/2020 02/28/2021 HRH MEDTECH AMAI PAKPAK MEDICAL CENTER 41000 15 JOB ORDER Y

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 1, 2024

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 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/ SPONSORED BY
NUMBER OF HOURS
(Write in full) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To
SEMINAR WORKSHOP ON MANUAL OF OPERATION FOR SCREENING DRUG
10/16/2019 10/18/2019 NATIONAL REFERENCE LABORATORY
TESTING LABORATORIES
BASIC LIFE SUPPORT TRAINING 11/30/2023 11/30/2023 AMAI PAK PAK MEDICAL 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
(Write in full)
in full)

COMPUTER LITERATE N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 1, 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? 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? ________________________________
________________________________
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
CHARITO MAATA, RMT AMAI PAK PAK MEDICAL CENTER 09562454453 3.5 cm. X 4.5 cm
(passport size)

ASLIA M. MAPANDI, MD, FPSMS, DPSP AMAI PAK PAK MEDICAL CENTER 09776150617 With full and handwritten
name tag and signature over
printed name
SOHRIA ABUBACAR-SARUANG ,MD AMAI PAK PAK MEDICAL CENTER 09171582120
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.: 0094378

Signature (Sign inside the box)
JANUARY 1, 2024
Date/Place of Issuance: 4/12/2019 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.

ATTY. ESNIHAIRAH M. DISANGCOPAN

Person Administering Oath

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