CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misinterpretation 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 BILLONES
NAME EXTENSION (JR., SR
FIRST NAME AIRA MAE

MIDDLE NAME LLASUS

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy)
11/19/1993
4. PLACE OF BIRTH SAN JOSE, ANTIQUE If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX

17. RESIDENTIAL ADDRESS GEF

6 CIVIL STATUS
House/Block/Lot No. S
POB
Subdivision/Village Ba
TIBIAO AN
7. HEIGHT (m) 1.62M
City/Municipality Pr
8. WEIGHT (kg) 72 KG ZIP CODE 5707

18. PERMANENT ADDRESS GEF

9. BLOOD TYPE B+
House/Block/Lot No. S
POB
10. GSIS ID NO.
Subdivision/Village Ba
TIBIAO
11. PAG-IBIG ID NO. 1211-5556-7305
City/Municipality Pr

12. PHILHEALTH NO. 02-026589250-8 ZIP CODE 5707

13. SSS NO. 07-3289871-3 19. TELEPHONE NO.

14. TIN NO. 323422514 20. MOBILE NO. 09179578246

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) aiibillones19@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/ A 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) N/A
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME BILLONES

JR
FIRST NAME ROGER
 MIDDLE NAME DERRAMAS

25. MOTHER'S MAIDEN NAME

SURNAME LLASUS

FIRST NAME MA. YVETTE

MIDDLE NAME GALAN (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)
From To

ELEMENTARY TIBIAO CENTRAL SCHOOL 6/6/2000 3/30/2006

UNIVERSITY OF ANTIQUE LABORATORY HIGH

SECONDARY /
VOCATIONAL SCHOOL -TLMC
6/10/2006 3/30/2010

TRADE
COURSE
COLLEGE ILOILO DOCTORS' COLLEGE BACHELOR OF SCIENCE IN NURSING 6/10/2010 3/30/2014

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE CS FORM 212 (Re

nal case/s against the person

(Do not fill up. For CSC use only)

XTENSION (JR., SR)

dicate country:

GEFES ST.,
Street
POBLACION
Barangay
ANTIQUE
Province

GEFES ST.,
Street
POBLACION
Barangay
ANTIQUE
Province

DATE OF BIRTH (mm/dd/yyyy)

heet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

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
PHILIPPINE NURSING LICENSURE
80.2 11/1/2015 ILOILO CITY, PHILIPPINES 0858175 11/19/2021
EXAMINATION

(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)
4
03/05/15 06/25/15 VOLUNTER NURSE CULASI DISTRICT HOSPITAL N/A VOLUNTARY
MONTHS
14000/MONT PROBITIONA 6
02/01/16 06/31/2016 STAFF NURSE DELIVERY SUITE, THE MEDICAL CITY H RY MONTHS
CUSTOMER SERVICE 16000/MONT 4
09/20/16 01/28/17 ALORICA PHILIPPINES SEASONAL
REPRESENTATIVE H MONTHS
ANGEL SALAZAR MEMORIAL GENERAL CONTRACT 3
04/01/17 06/30/17 VOLUNTER NURSE 5000/MONTH
HOSPITAL OF SERVICE MONTHS
ANGEL SALAZAR MEMORIAL GENERAL 5000.00/MO CONTRACT 6
7/1/2017 12/31/2017 VOLUNTER NURSE NTH
HOSPITAL OF SERVICE MONTHS
ANGEL SALAZAR MEMORIAL GENERAL CONTRACT
1/1/2018 6/30/2018 VOLUNTER NURSE
HOSPITAL OF SERVICE
ANGEL SALAZAR MEMORIAL GENERAL CONTRACT
HOSPITAL OF SERVICE

(Continue on separate sheet if necessary)

SIGNATURE DATE 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 / N
From To

(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/ SP
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To
ASSOCIATON
REGULAR IV TRAINING PROGRAM 6/5/2015 6/7/2015 24.0
ADMINISTRAT
AESCULAP AC
PERIOPERATIVE NURSING 101 COURSE (DIDACTICS) 8/6/2015 9/19/2015 80.0
ORTIGAS

PERIOPERATIVE NURSING 101 COURSE (CLINIC) 8/9/2015 8/29/2015 35.0 THE MEDICAL

NURSE TRAINING ADAPTIVE PROGRAM (DIDACTICS) 10/19/2015 10/30/2015 80.0

THE MEDICA

NURSE TRAINING ADAPTIVE PROGRAM (CLINICAL EXPOSURE) 11/23/2016 12/11/2015 120.0 THE MEDICAL
 (Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSH
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

(Continue on separate sheet if necessary)

SIGNATURE DATE
EOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

te sheet if necessary)

GRAMS ATTENDED
(5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

ASSOCIATON OF NURSING SERVICE

ADMINISTRATOR OF THE PHILIPPINES
AESCULAP ACADEMY/ THE MEDICAL CITY
ORTIGAS

THE MEDICAL CITY

THE MEDICAL CITY

THE MEDICAL CITY

te sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION

(Write in full)

te sheet if necessary)

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
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
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 administrative/criminal case/s against me.

42.
is not acceptable

PHOTO
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

ID/License/Passport No.: 0858175

Signature (Sign inside the box)

Date/Place of Issuance: 3/30/15

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

above.

17), Page 4 of 4