CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

Print ligibly. Mark appropriate boxes

"with"

and use separate sheet if necessary

1. CS ID NO.

I. PERSONAL INFORMATION

P OR T U L A

2. SURNAME
FIRST NAME

C H E R R Y

MIDDLE NAME

M O N T E

R O

//

A N N E
N

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

DECEMBER 14, 1985

5. PLACE OF BIRTH

TACLOBAN CITY, LEYTE

16. RESIDENTIAL ADDRESS

Block 8 lo

TACLOB

6. SEX

Male

Female

7. CIVIL STATUS

Single

Widowed

Married

Separated

17. TELEPHONE NO.

Annuled

Others, specify

18. PERMANENT ADDRESS

ZIP CODE

6500

Block 8 lo

8. CITIZENSHIP

FILIPINO

TACLOB

9. HEIGHT (m)

1.25 M

10. WEIGHT (kg)

50 kg

11. BLOOD TYPE

"O"

19. TELEPHONE NO.

(053) 832

12. GSIS ID NO.

NONE

20. E-MAIL ADDRESS (if any)

marie_ag

13. PAG-IBIG ID NO.

21. CELLPHONE NO. (if any)

9166250

14. PHILHEALTH NO.

22. AGENCY EMPLOYEE NO.

ZIP CODE

06-2752625-5

15. SSS NO.

6500

281-332-

23. TIN NO.

II. FAMILY BACKGROUND

24. SPOUSE SURNAME

N/A

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

N/A

FIRST NAME
MIDDLE NAME
OCCUPATION
EMPLOYER/BUS. NAME
BUSNESS ADDRESS
TELEPHONE NO.
(Continue on separate sheet if necessary)
26. FATHER'S SURNAME

AGUILOS

FIRST NAME

FLORENCIO Jr.

MIDDLE NAME

GRANADOS

27. MOTHER'S MAIDEN NAME

GRANA

SURNAME

AGUILOS

FIRST NAME

ANTONIA (Deceased)

MIDDLE NAME

GRANA

(Continue on separate sheet if n

III. EDUCATIONAL BACKGROUND

28

YEAR

LEVEL

HIGHEST GRADE/

NAME OF SCHOOL

DEGREE COURSE

GRADUATED

LEVEL/

(Write in full)

(Write in full)

(if graduated)

UNITS EARNED
(if not graduated)

ELEMENTARY

ST.THERESE CHILD

PRIMARY

INCLUSIVE DA

ATTENDAN
From

1999

1993

1999

1999

DEVELOPMENT CENTER
LEYTE INSTITUTEOF

SECONDARY

TECHNOLOGY

VOCATIONAL/
TRADE COURSE

COLLEGE

ST. SCHOLASTICA'S

BACHELOR OF SCIENCE

COLLEGE OF

IN

HEALTH SCIENCES

NURSING

2007

GRADUATE STUDIES
(Continue on separate sheet if necessary)

2003

L DATA SHEET
(to be filed up by CSC)

//

Block 8 lot 4 Barangay 72 PHHC,

TACLOBAN CITY
6500
Block 8 lot 4 Barangay 72 PHHC,
TACLOBAN CITY
6500
(053) 832-4439
marie_aguilos@yahoo.com
9166250631
281-332-469

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

DATE OF BIRTH (mm/dd/yyyy)

N/A

(Continue on separate sheet if necessary)

INCLUSIVE DATES OF

SCHOLASHIP

ATTENDANCE

ACADEMIC HONORS
RECEIVED

From

To

1993

1999

Graduate

1999

2003

Graduate

2003

2007

Graduate

eparate sheet if necessary)

Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY

29

DATE OF
CAREER SERVICE/RA 1080 (BOARD/BAR)

RATING

EXAMINATION/

UNDER SPECIAL LAWS/C ES/CSEE

CONFERMENT

NURSING LICENSURE EXAMINATION

6/10/2007

PLACE OF EXAMINATION/ CONFERMENT

TACLOBAN CITY, PHILIPPINES

(Continue on separate sheet if necessary)

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

SALARY GRADE
INCLUSIVE DATES

POSITION TITLE

DEPARTMENT/AGENCY/OFFICE/COMPANY

MONHTLY

& STEP

(mm/dd/yyyy)

(Write in full)

(Write in full)

SALARY

INCREMENT

From

To

(Format "00-1")

8/1/2008

8/31/2008

Nurse

Bethany Hospital assigned in Intensive Care Unit

9/1/2008

10/31/2008

Nurse

Bethany Hospital assigned in OB-DR, Dialysis Unit

and Intensive Care Unit

11/1/2009

1/31/2009

Staff Nurse I

Bethany Hospital assigned in OB-NICU

7,000.00

2/1/2009

4/30/2009

Staff Nurse I

Bethany Hospital assigned in OB-NICU

7,000.00

5/1/2009

3/31/2013

Staff Nurse I

Bethany Hospital assigned in OB-NICU

10,300.00

4//1/2013

8/31/2013

Staff Nurse II

Medical, Surgical, Pediatric Ward

12,300.00

9/1/2013

12/22/2013

Staff Nurse II

Bethany Hospital assigned in OB-NICU

12,300.00

10/22/2013

4/10/2014

Nurse

Medecins Sans Frontieres assigned in NICU

24,000.00

06/1/2014

Present

Nurse

Medecins Sans Frontieres assigned in NICU

24,400.00

(Continue on separate sheet in necessary)

CS FORM 212 (

LICENSE (if applicable)

NUMBER

460828

DATE OF
RELEASE

12/13/2007

eparate sheet if necessary)

current work)
GOV'T
STATUS OF

SERVICE

APPOINTMENT

(Yes / No)

Orientee

No

Trainee

No

Contractual

No

Probationary

No

Regular

No

Regular

No

Regular

No

Casual

No

Casual

No

eparate sheet in necessary)

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

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

31.

NAME & ADDRESS OF ORGANIZATION

(Write in full)

INCLUSIVE DATES
(mm/dd/yyyy)
From

NUMBER OF
HOURS
To

N/A

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

32
32.

TITLE OF SEMINAR / CONFERENCE/

WORKSHOP / SHORT COURSES

INCLUSIVE DATES OF ATTENDANCE

(mm/dd/yyyy)

NUMBER OF
HOURS

(Write in full)

From

To

Kangaroo Mother Care Program (TOT)

10/6/2014

10/10//2014

40

Breastfeeding Congress Part 1

8/1/2013

8/2/2013

12

Basic I.V Therapy Training

5/7/2012

5/9/2012

24

Basic Life Support Training

11/17/2011

11/18/2011

16

Costumer Relationship Enhancement &

7/23/2011

Management (CREAM) Seminar Workshop

Breastfeeding Promotion and Support in a

12/6/2010

12/7/2010

Baby Friendly Hospital

(Continue on separate sheet if necessary)

VII. OTHER INFORMATION

20

33.

34.
SPECIAL SKILLS/HOBBIES

NON-ACADIMIC DISTICNTIONS / RECOGNITION:

(Write in full)

COMPUTER COMPETENT

(Continue on separate sheet if necessary)

CS FORM 212 (

POSITION / NATURE OF WORK

CONDUCTED / SPONSORED BY
(Write in full)

KMC Foundation and WHO

Philippine Pediatric Society
ANSAP Accredited, RTRMF
Philippine Red Cross
Human Resource Department in
Bethany Hospital

Nursing Service Department in

Bethany Hospital

35.

MEMBERSHIP IN
ASSOCIATION / ORGANIZATION
(Write in full)

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

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

a. With in the third degree (for National Government Employees):
appointing authority, reccomending 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 Employee):

appointing authority or recommending authority where you will be appointed?

YES
NO
//
If YES, give details:

37. a. Have you ever been formally charge?

YES
NO
If YES, give details:

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

YES
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?

YES
NO
If YES, give details:

39. Have you even separated from the service in any of the following modes:
resignation, retirement, dropped from the rools, dismissal, termination, end of
term, finished contract, AWOL or phased out, in the public or private sector?

YES
NO
If YES, give details:

40. Have you ever been a candidate in a national or local election

(except Barangay election)?

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 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, give details:

b. Are you different abled?

YES
NO
If YES, give details:

c. are you a solo parent?

YES
NO
If YES, give details:

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

NAME
AUDREY KATHARINA SANTO, MD,DPPS

DR. GERALYN GO, MD, DPPS

ELNORA ARGOTA R.N. MAN

ADDRESS

TEL NO.

PEDIATRICIAN-NEONATOLOGIST,TACLOBAN

9173214917

PEDIATRICIAN, TACLOBAN CITY

9228194235

PNA GOVERNOR, LEYTE

9195557514

43. 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.

ID picture taken within

the last 6 months
3.5 cm x 4.5 cm
(passport size)
Computer generated
or xerox copy of picture
is not acceptable

PHOTO

36378358

COMMUNITY TAX CERTIFICATE NO.

TACLOBAN CITY
ISSUED AT

12/3/2014

ISSUED ON (mm/dd/yyyy)

SIGNATURE (Sign inside the box)

3/3/2015
DATE ACCOMPLISHED

RIGHT THUMBMARK

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