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CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET


Print legibly. Mark appropriate boxes

with "

1. CS ID No.

" and use separate sheet if necessary.

(to be filled up by CSC)

I. PERSONAL INFORMATION
S|A |M|S|O |N|

2. SURNAME

FIRST NAME

G| I |L|B|E|R| T| |

MIDDLE NAME

C|O|M|F|O|R |T|O|

5. PLACE OF BIRTH

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3. NAME EXTENSION (e.g. Jr., Sr.)

16. RESIDENTIAL ADDRESS

09/21/1991

4. DATE OF BIRTH (mm/dd/yyyy)

NORZAGARAY BULACAN
Fem ale

6. SEX

Male

7. CIVIL STATUS

Single

Widowed

Married

Separated
17. TELEPHONE NO.
Others, specify ___________ 18. PERMANENT ADDRESS

Annulled
8. CITIZENSHIP

FILIPINO

9. HEIGHT (cm)

165 cm

10. WEIGHT (kg)

70 kgms

ZIP CODE

455 Ipo Rd. San Mateo, Norzagaray, Bulacan

ZIP CODE

3013

11. BLOOD TYPE

19. TELEPHONE NO.

12. GSIS ID NO.

20. E-MAIL ADDRESS (if any)

gilbert.samson28@yahoo.com

13. PAG-IBIG ID NO.

21. CELLPHONE NO. (if any)

0915-298-7572

14. PHILHEALTH NO.

22. AGENCY EMPLOYEE NO.

15. SSS NO.

004-149-597

23. TIN

34-3185327-6

II. FAMILY BACKGROUND


24. SPOUSE'S SURNAME

25. NAME OF CHILD (Write full name and list all)

DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUS. NAME

BUSINESS ADDRESS

TELEPHONE NO.

SAMSON

FIRST NAME

ALFREDO

MIDDLE NAME

CORREA

(Continue on separate sheet if necessary)


26. FATHER'S SURNAME

27. MOTHER'S MAIDEN NAME


SURNAME

COMFORTO

FIRST NAME

ANNABELLA

MIDDLE NAME

LUCAS

(Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND


28.

YEAR
GRADUATED

NAME OF SCHOOL
LEVEL

(Write in

INCLUSIVE DATES OF
ATTENDANCE

HIGHEST GRADE/
LEVEL/
UNITS EARNED
(if not graduated)

DEGREE COURSE
(Write in full)

full)

(if graduated)

From

To

ELEMENTARY

San Mateo Elementary School

Primary

2004

1998

2004

SECONDARY
VOCATIONAL /

Julian B. Sumbillo High School

Secondary

2008

2004

2008

Norzagaray College

B.S Nursing

2012

2008

2012

COLLEGE
COURSE

SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED

TRADE

GRADUATE STUDIES

(Continue on separate sheet if necessary)


Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY


29.

CAREER SERVICE/ RA 1080 (BOARD/ BAR)


UNDER SPECIAL LAWS/ CES/ CSEE

Nursing Licensure Examination

RATING

75.40%

LICENSE (if applicable)

DATE OF
EXAMINATION /
CONFERMENT

PLACE OF EXAMINATION / CONFERMENT

November
29-30 , 2014

Manila

NUMBER

DATE OF
RELEASE

0853888

02/20/16

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work)
30.

INCLUSIVE DATES
(mm/dd/yyyy)

POSITION TITLE

DEPARTMENT / AGENCY / OFFICE / COMPANY


(Write in full)

(Write in full)

GOV'T
SERVICE
MONTHLY
SALARY

SALARY GRADE
& STEP
INCREMENT
(Format "00-0")

STATUS OF
APPOINTMENT

From

To

07 / 01 /15

12 / 31 / 16

Nurse

Rural Health Unit II

5,720

Job Order

01 / 01 /16

06 / 30 / 16

Nurse

Rural Health Unit II

5,720

Job Order

06 / 01 /15

12 / 31 / 15

Nurse

Rural Health Unit II

5,720

Job Order

04 / 15 / 15

05 / 31 / 15

Nurse

NA

Volunteer

Norzagaray Municipal Hospital

(Yes / No)

(Continue on separate sheet if necessary)


CS FORM 212 (Revised 2005), Page 2 of 4

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S


31. NAME & ADDRESS OF ORGANIZATION

INCLUSIVE DATES
(Write in full)

NUMBER OF
HOURS

(mm/dd/yyyy)
From

POSITION / NATURE OF WORK

To

(Continue on separate sheet if necessary)

VII. TRAINING PROGRAMS (Start from the most recent training.)


INCLUSIVE DATES OF ATTENDANCE
32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write
in full)

Electrotechnical Institute of Bataan

(mm/dd/yyyy)
From

To

01 / 05 / 15

01 / 20 / 15

NUMBER OF
HOURS

CONDUCTED/ SPONSORED BY
(Write in full)

72 hours

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


33.

SPECIAL SKILLS / HOBBIES:

NON-ACADEMIC DISTINCTIONS / RECOGNITION:


34.
(Write in full)

35.

MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(Write in full)

Computer Literate ( MS OFFICE )

(Continue on separate sheet if necessary)


CS FORM 212 (Revised 2005), Page 3 of 4

36.

Are you related by consanguinity or affinity to any of the following :

a.

Within the third degree (for National Government Employees):


appointing authority, recommending authority, chief of office/bureau/department or person who
has immediate supervision over you in the Office, Bureau or Department where you will be
appointed?

YES NO
If YES, give details:
_____________________________________
_____________________________________
_____________________________________

b.

Within the fourth degree (for Local Government Employees):


appointing authority or recommending authority where you will be appointed?

YES
NO
If YES, give details:
_____________________________________
_____________________________________
_____________________________________

37

a. Have you ever been formally charged?

YES

NO

If YES, give details:


________________________________
________________________________
YES

b. Have you ever been guilty of any administrative offense?

NO

If YES, give details:


________________________________
________________________________
38.

Have you ever been convicted of any crime or violation of any law, decree, ordinance or
regulation by any court or tribunal?

39.

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, AWOL or
phased out, in the public or private sector?

40.

Have you ever been a candidate in a national or local election (except Barangay election)?

YES
NO
If YES, give details:
________________________________
________________________________
YES

NO

If YES, give details:


________________________________
________________________________
YES

NO

If YES, give details:


________________________________
________________________________
41.

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?

b.

Are you differently abled?

c.

Are you a solo parent?

YES
NO
If YES, please specify: ____________________
YES
NO
If YES, please specify: ____________________
YES
NO
If YES, please specify: ____________________

42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)


NAME

Mayor : Geronimo " Ade " Cristobal


Mayor : Alfredo Germar
Councilor : Jerry Sumbillo
43.

ADDRESS

TEL. NO.

Norzagaray , Bulacan
Norzagaray , Bulacan

ID picture taken within


the last 6 months
3.5 cm. X 4.5 cm
(passport size)

San Mateo, Norzagaray Bulacan

I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the
Philippines.
I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust
that this information shall remain confidential.

Computer generated
or xerox copy of picture
is not acceptable

PHOTO

32199724
COMMUNITY TAX CERTIFICATE NO.

Norzagaray Bulacan
ISSUED AT

07/04/2016
ISSUED ON (mm/dd/yyyy)

SIGNATURE (Sign inside the box)

12/15/2016
DATE ACCOMPLISHED

RIGHT THUMBMARK

CS FORM 212 (Revised 2005), Page 4 of 4