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 aga
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 CARBONELL
NAME EXTENSION (JR., SR)
FIRST NAME LIZA MARIE
MIDDLE NAME EDUL
3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 01/02/1985 ✘ Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH PAGADIAN CITY If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS No. 0392 BONIFACIO EXTENSI
Widowed Separated House/Block/Lot No. S
SAN JOS
Other/s:
Subdivision/Village Bar
PAGADIAN CITY ZAMBOAN
7. HEIGHT (m) 1.58 m.
City/Municipality Pro
8. WEIGHT (kg) 63 kgs. ZIP CODE 7016

18. PERMANENT ADDRESS No. 0392 BONIFACIO EXTENSI

9. BLOOD TYPE "B+"
House/Block/Lot No. S
SAN JOS
10. GSIS ID NO. N/A
Subdivision/Village Bar
PAGADIAN CITY ZAMBOAN
11. PAG-IBIG ID NO. 121109259403
City/Municipality Pro

12. PHILHEALTH NO. 12-050491060-7 ZIP CODE 7016

13. SSS NO. 625533907 19. TELEPHONE NO. N/A

14. TIN NO. 246-472-625-000 20. MOBILE NO. 09483770183

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) lizamariecarbonell@yahoo.co
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)

NAME EXTENSION (JR., SR)

FIRST NAME N/A N/A

MIDDLE NAME N/A N/A

OCCUPATION N/A N/A

EMPLOYER/BUSINESS NAME N/A N/A

BUSINESS ADDRESS N/A N/A

TELEPHONE NO. N/A N/A

24. FATHER'S SURNAME CARBONELL N/A

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

MIDDLE NAME ZAMORA N/A

25. MOTHER'S MAIDEN NAME N/A

SURNAME EDUL N/A

FIRST NAME CYNTHIA N/A

MIDDLE NAME HERSIŇADA (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)
 BASIC EDUCATION/DEGREE/COURSE UNITS
LEVEL (Write in EARNED
(Write in full)
full) (if not graduated)
From To

ELEMENTARY PAGADIAN CITY PILOT SCHOOL PRIMARY EDUCATION 1992 1998 N/A
ZAMBOANGA DEL SUR
SECONDARY /
VOCATIONAL SECONDARY EDUCATION 1998 2002 N/A
NATIONAL HIGH SCHOOL
N/A N/A N/A N/A N/A
TRADE
FAR EASTERN UNIVERSITY - BACHELOR OF SCIENCE IN
COURSE 2002 2003 N/A
MANILA NURSING
SOUTHWESTERN UNIVERSITY - BACHELOR OF SCIENCE IN
COLLEGE 2003 2005 N/A
CEBU CITY NURSING
MEDINA COLLEGE PAGADIAN BACHELOR OF SCIENCE IN
2007 2010 N/A
CITY NURSING
GRADUATE STUDIES N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE July 1

CS FORM
 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:

BONIFACIO EXTENSION, SALAZAR STREET,

Street
SAN JOSE DISTRICT
Barangay
ZAMBOANGA DEL SUR
Province
7016

BONIFACIO EXTENSION, SALAZAR STREET,

Street
SAN JOSE DISTRICT
Barangay
ZAMBOANGA DEL SUR
Province

7016

N/A

09483770183

lizamariecarbonell@yahoo.com

DATE OF BIRTH (mm/dd/yyyy)

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A
(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED
 ACADEMIC
GRADUATED
HONORS
RECEIVED

1998 DIPLOMA

2002 DIPLOMA

N/A N/A

Transferred N/A

Transferred N/A

2010 DIPLOMA

N/A N/A
parate sheet if necessary)

July 1, 2019
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 applic
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

NURSING LICENSURE JULY 2-3,

76.40% PAGADIAN CITY 0723067
EXAMINATION 2011

(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
(mm/dd/yyyy) SALARY/
JOB/ PAY
GRADE (if
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY applicable)
MONTHLY
(Write in full/Do not SALARY
& STEP STATUS OF APPOINTMENT
(Format
abbreviate) (Write in full/Do not abbreviate) "00-0")/
From To INCREME
NT

NURSE DEPLOYMENT PROJECT (NDP)/ DEPARTMENT OF HEALTH - CONTRACT OF

2/22/2019 3/30/2019 29,010.00
NURSE 2 REGIONAL OFFICE IX SERVICE

NURSE DEPLOYMENT PROJECT (NDP)/ DEPARTMENT OF HEALTH - CONTRACT OF

1/1/2018 12/31/2018 31,765.00 SG15
NURSE 2 REGIONAL OFFICE IX SERVICE

NURSE DEPLOYMENT PROJECT (NDP)/ DEPARTMENT OF HEALTH - CONTRACT OF

1/1/2017 12/31/2017 26,878.00 SG14
NURSE 2 REGIONAL OFFICE IX SERVICE

NURSE DEPLOYMENT PROJECT (NDP)/ DEPARTMENT OF HEALTH - CONTRACT OF

1/1/2016 12/31/2016 26,878.00 SG14
NURSE 2 REGIONAL OFFICE IX SERVICE

NURSE DEPLOYMENT PROJECT (NDP)/ DEPARTMENT OF HEALTH - CONTRACT OF

1/1/2015 12/31/2015 18,549.00 SG10
NURSE 1 REGIONAL OFFICE IX SERVICE

NURSE DEPLOYMENT PROJECT (NDP)/ DEPARTMENT OF HEALTH - CONTRACT OF

1/1/2014 12/31/2014 18,549.00 SG10
NURSE 1 REGIONAL OFFICE IX SERVICE

REGISTERED NURSES FOR HEALTH

DEPARTMENT OF HEALTH - CONTRACT OF
3/1/2013 12/31/2013 OPPORTUNITIES THRU PROGRAM 16, 000.00
REGIONAL OFFICE IX SERVICE
EXCELLENCE (RN HOPE)
LEONA CAKES & PASTRIES,
2/8/2008 10/31/2008 CASHIER/ SERVICE CREW LEONA FOOD VENTURES 6,000.00 CONTRACTUAL
CORPPORATION, CEBU CITY
MULTI-STORE CORPORATION, SM
8/1/2006 12/31/2006 SALES CLERK DEPARTMENT STORE, SM CITY 5,000.00 CONTRACTUAL
CEBU

TRIPLE V - EXPRESS, SM CITY

11/1/2005 4/30/2006 COUNTER CREW 5,000.00 CONTRACTUAL
CEBU
 (Continue on separate sheet if necessary)

SIGNATURE DATE JULY 01, 2019

CS FORM 212 (Revise
 LICENSE (if applicable)

Date of
Validity

01/02/2020

arate sheet if necessary)

GOV'T SERVICE

(Y/ N)

N
arate sheet if necessary)

JULY 01, 2019

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
From To
PHILIPPINE NURSES ASSOCIATION - ZAMBOANGA DEL SUR
1/1/2018 12/31/2018 N/A MEMBER
CHAPTER
UNITED CHURCH OF CHRIST IN THE PHILIPPINES - BOARD
6/1/2018 5/31/2020 N/A SECRETARY
OF CHRISTIAN EDUCATORS - PAGADIAN CITY
UNITED CHURCH OF CHRIST IN THE PHILIPPINES -
5/1/2018 5/1/2020 N/A P.I.O.
CHRISTIAN YOUNG ADULT FELLOWSHIP MARK CHAPTER
(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
TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORE
PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy)
Technical/etc)
(Write in full) From To

PHILIPPINE NURS
PHILIPPINE NURSES ASSOCIATION - 5th REGIONAL
ZAMBOANGA DEL
CONVERGENCE SUMMIT 2018 WITH APPROVED CPD UNITS 10-6-2018 10-6-2018 8 HOURS
CHAPTER & OFF
7.0
GOVERNOR

DEPARTMENT OF
BASIC LIFE SUPPORT - CARDIOPULMONARY
07-10-2018 07-11-2018 16 HOURS OFFICE IX - HEA
RESUSCITATION FOR HEALTH CARE PROVIDER
MANAGEM

ORIENTATION TRAINING ON NATIONAL IMMUNIZATION DEPARTMENT OF

9/12/2017 9/14/2017 24 HOURS
PROGRAM OFFI

ORIENTATION ON EO 12 & DOH AO NO.005 & TRAINING

COMISSION ON
WORKSHOP ON GUIDELINES AND ENHANCED RP-FP 9/7/2017 9/8/2017 16 HOURS
REGIONAL
MONITORING SYSTEM

NEW GARANTISADONG PAMBATA ORIENTATION 4/7/2017 4/7/2017 5 HOURS CITY HEALTH OF

PHILIPPINE SOCIET
TRAINING IN PROGESTIN-ONLY SUBDERMAL IMPLANT PARENTHOOD - JOHNS
3/15/2017 3/16/2017 16 HOURS INTERNATIONAL EDUC
PROVISION
AND OBSTETRICS -

INTER-PERSONAL COMMUNICATION AND COUNSELING DEPARTMENT OF

9/28/2015 10/2/2015 40 HOURS
TRAINING & HI-IMPACT FIVE ORIENTATION OFFI

NURSE DEPLOYMENT PROJECT PROGRAM DEPARTMENT OF

5/21/2015 5/22/2015 16 HOURS
IMPLEMENTATION REVIEW AND RAIDERS ORIENTATION OFFI

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES DEPARTMENT OF

11/10/2014 11/11/2014 16 HOURS
TRAINING OFFI

SCHISTOSOMIASIS CASE MANAGEMENT/ CLINICAL DEPARTMENT OF

10/23/2014 10/24/2014 16 HOURS
PRACTICE GUIDELINE UPDATE OFFI

TRAINING ON INTERPERSONAL COMMUNICATION AND PROVINCE OF ZAM

COUNSELING SKILLS FOR HEALTH SERVICE PROVIDERS 10/15/2014 10/17/2014 24 HOURS INTEGRATED PRO
OF ZAMBOANGA DEL SUR OFF

DEPARTMENT OF
FAMILY PLANNING COMPETENCY BASED TRAINING 1 8/25/2014 8/29/2014 40 HOURS
OFFI

DEPARTMENT OF
2011-2016 NATIONAL TOBACCO CONTROL STRATEGY 10/31/2013 10/31/2013 8 HOURS FOR HEALTH D
DISSEMINATION ZAMBOANGA
HOPE: A REVIEW ON MATERNAL, NEONATAL, CHILD DEPARTMENT OF
HEALTH, AND NUTRITION PROGRAM IMPLEMENTATION IN 10/29/2013 10/31/2013 24 HOURS FOR HEALTH D
ZAMBOANGA DEL SUR ZAMBOANGA
TRAINING ON INFANT & YOUNG CHILD FEEDING, DEPARTMENT OF
MICRONUTRIENT SUPPLEMENTAION , & GROWTH 9/3/2013 9/5/2013 24 HOURS FOR HEALTH D
MONITORING & PROMOTION ZAMBOANGA
2-DAY KALUSUGANG PANGKALAHATAN - COMMUNITY
DEPARTMENT OF
HEALTH TEAM CONSULTATIVE AND AREA-BASED
3/14/2013 3/15/2013 16 HOURS FOR HEALTH D
PLANNING WORKSHOP ADDRESSING HEALTH USE PLAN
ZAMBOANGA
GAPS
DEPARTMENT OF
REGISTERED NURSES FOR HEALTH ENHANCEMENT AND
3/5/2012 2/28/2013 1 YEAR FOR HEALTH D
LOCAL SERVICES BATCH 3 (RN HEALS 3)
ZAMBOANGA

ZAMBOANGA DE
VOLUNTEER NURSE 11/11/2011 2/29/2012 3 MONTHS
CEN

VIII. OTHER INFORMATION

MEMBERSHIP IN ASS
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)
(W

COMPUTER LITERATE (MICROSOFT WORD,

N/A N
EXCEL, AND POWER POINT)
HOSTING/ FACILITATING PROGRAMS OR
N/A N
EVENTS
SKETCHING/ DRAWING KARANGALANG JUAN LUNA, POSTER MAKING CONTEST WINNER N
(Continue on separate sheet if necessary)

SIGNATURE DATE JULY 0

CS FORM 212
ERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

MEMBER

SECRETARY

P.I.O.
on separate sheet if necessary)
AINING PROGRAMS ATTENDED
aken for the last five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

PHILIPPINE NURSES ASSOCIATION

ZAMBOANGA DEL SUR - PAGADIAN
CHAPTER & OFFICE OF THE PNA
GOVERNOR, REGION IX

DEPARTMENT OF HEALTH REGIONAL

OFFICE IX - HEALTH EMERGENCY
MANAGEMENT STAFF

DEPARTMENT OF HEALTH REGIONAL

OFFICE IX

COMISSION ON POPULATION -
REGIONAL OFFICE IX

CITY HEALTH OFFICE - PAGADIAN

PHILIPPINE SOCIETY FOR RESPONSIBLE

PARENTHOOD - JOHNS HOPKINS PROGRAM FOR
INTERNATIONAL EDUCATION IN GYNECOLOGY
AND OBSTETRICS - MINDANAO HEALTH

DEPARTMENT OF HEALTH REGIONAL

OFFICE IX

DEPARTMENT OF HEALTH REGIONAL

OFFICE IX

DEPARTMENT OF HEALTH REGIONAL

OFFICE IX

DEPARTMENT OF HEALTH REGIONAL

OFFICE IX

PROVINCE OF ZAMBOANGA DEL SUR

INTEGRATED PROVINCIAL HEALTH
OFFICE

DEPARTMENT OF HEALTH REGIONAL

OFFICE IX

DEPARTMENT OF HEALTH CENTER

FOR HEALTH DEVELOPMENT
ZAMBOANGA PENINSULA
DEPARTMENT OF HEALTH CENTER
FOR HEALTH DEVELOPMENT
ZAMBOANGA PENINSULA
DEPARTMENT OF HEALTH CENTER
FOR HEALTH DEVELOPMENT
ZAMBOANGA PENINSULA
 DEPARTMENT OF HEALTH CENTER
FOR HEALTH DEVELOPMENT
ZAMBOANGA PENINSULA
DEPARTMENT OF HEALTH CENTER
FOR HEALTH DEVELOPMENT
ZAMBOANGA PENINSULA

ZAMBOANGA DEL SUR MEDICAL

CENTER

MEMBERSHIP IN ASSOCIATION/ORGANIZATION

(Write in full)

N/A

N/A

N/A
on separate sheet if necessary)

JULY 01, 2019

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? FINISHED CONTRACT
________________________________
________________________________
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 w
PROVINCIAL DEPARTMENT OF the last 6 mont
3.5 cm. X 4.5 c
AGNES E. FERNANDO, DMO V HEALTH OFFICE ZAMBOANGA 9204393664 (passport size
DEL SUR
With full and handw
CITY HEALTH OFFICE - 2144-420/ name tag and signatu
NOEL E. CENIZA, CHO II printed name
PAGADIAN 2154132
CITY HEALTH OFFICE - Computer genera
MAGDALENA A. JANOLINO, PHN V 9206019375 or photocopied pic
PAGADIAN is not acceptab
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.: 0723067 Signature (Sign inside the box)

Date/Place of Issuance: 1-3-17 / PAGADIAN CITY

JULY 01, 2019
Date Accomplished Right Thumbma

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated
Person Administering Oath

CS FORM 212 (Revis

 If YES, give details:
________________________________

If YES, give details:

________________________________
________________________________

If YES, give details:

________________________________
________________________________

If YES, give details:

________________________________
________________________________

If YES, give details:

FINISHED CONTRACT
________________________________
________________________________

✘ NO

If YES, give details (country):

✘ NO

✘ NO

✘ NO

ID picture taken within

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

With full and handwritten

name tag and signature over
printed name

Computer generated
or photocopied picture
is not acceptable

PHOTO

Right Thumbmark

, affiant exhibiting his/her validly issued government ID as indicated above.

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