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 DATU
N/A
FIRST NAME LOURDES GAIL

MIDDLE NAME TOLENTINO

3. DATE OF BIRTH
(mm/dd/yyyy) 9/6/1979 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH MANILA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS BLK 9 LOT39

Widowed Separated House/Block/Lot No. Street
TIERRA VISTA SUBD., SAN RAFAEL
Other/s:
Subdivision/Village Barangay
MEXICO PAMPANGA
7. HEIGHT (m) 1.58
City/Municipality Province
8. WEIGHT (kg) 48.98 ZIP CODE 2021

18. PERMANENT ADDRESS BLK 9 LOT39

9. BLOOD TYPE A+
House/Block/Lot No. Street
TIERRA VISTA SUBD., SAN RAFAEL
10. GSIS ID NO. N/A
Subdivision/Village Barangay
MEXICO PAMPANGA
11. PAG-IBIG ID NO. 105000873400
City/Municipality Province

12. PHILHEALTH NO. 07-251041507-9 ZIP CODE 2021

13. SSS NO. 33 708 5991 7 19. TELEPHONE NO. N/A

14. TIN NO. 216 042 521 000 20. MOBILE NO. 09171345358

15. AGENCY EMPLOYEE NO. 4234 21. E-MAIL ADDRESS (if any) lg13tolentino@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME DATU 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME DARWIN DARYLLE ANN T. DATU 9/14/2006

MIDDLE NAME NAGUIT LOURIN FAITH T. DATU 11/25/2008

OCCUPATION CIVIL ENGINEER

EMPLOYER/BUSINESS NAME DEPARTMENT OF PUBLIC WORKS & HIGHWAYS

BUSINESS ADDRESS GUAGUA, PAMPANGA

TELEPHONE NO. 9334705636

DECEASED
24. FATHER'S SURNAME TOLENTINO
NAME EXTENSION (JR., SR)
FIRST NAME BARTOLOME

MIDDLE NAME ELIZAGA

25. MOTHER'S MAIDEN NAME

SURNAME LEGASPI 5/19/1953

FIRST NAME MARILOU

MIDDLE NAME ILAS (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

ELEMENTARY MARILAO CENTRAL SCHOOL PRIMARY EDUCATION N/A 1992 N/A

SECONDARY /
VOCATIONAL ST.PAUL COLLEGE OF BOCAUE,BULACAN HIGHSCHOOL N/A 1996 N/A

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

TRADE
BACHELOR OF SCIENCE IN MEDICAL
COURSE
COLLEGE UNIVERSITY OF STO.TOMAS, MANILA
TECHNOLOGY N/A 2000 N/A

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

(Continue on separate sheet if necessary)

SIGNATURE DATE October 4, 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 ap
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

MEDICAL TECHNOLOGY LICENSURE

0.8 9/9/2000 UNIVERSITY OF THE EAST, MANILA 039950
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.
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

RICARDO P. RODRIGUEZ MEMORIAL

01/01/2018 PRESENT LABORATORY AIDE II ₱13,214.00 4-1 PERMANENT
HOSPITAL
RICARDO P. RODRIGUEZ MEMORIAL
1/1/2017 12/31/2017 LABORATORY AIDE II ₱11,181.00 4-1 PERMANENT
HOSPITAL
RICARDO P. RODRIGUEZ MEMORIAL
3/2/2016 12/31/2016 LABORATORY AIDE II ₱11,181.00 4-1 PERMANENT
HOSPITAL
RICARDO P. RODRIGUEZ MEMORIAL
1/1/2016 3/1/2016 MEDICAL TECHNOLOGIST I ₱17,100.00 NA JOB ORDER
HOSPITAL
RICARDO P. RODRIGUEZ MEMORIAL
7/1/2015 12/31/2015 MEDICAL TECHNOLOGIST I ₱17,100.00 NA JOB ORDER
HOSPITAL
RICARDO P. RODRIGUEZ MEMORIAL
1/1/2015 6/30/2015 MEDICAL TECHNOLOGIST I ₱17,100.00 NA JOB ORDER
HOSPITAL
RICARDO P. RODRIGUEZ MEMORIAL
7/1/2014 12/31/2014 MEDICAL TECHNOLOGIST I ₱17,100.00 NA JOB ORDER
HOSPITAL
RICARDO P. RODRIGUEZ MEMORIAL
1/1/2014 6/30/2014 MEDICAL TECHNOLOGIST I ₱17,100.00 NA JOB ORDER
HOSPITAL
RICARDO P. RODRIGUEZ MEMORIAL
7/1/2013 12/31/2013 MEDICAL TECHNOLOGIST I ₱17,100.00 NA JOB ORDER
HOSPITAL
11/15/2009 4/30/2013 MEDICAL TECHNOLOGIST BLOODLINE MEDICAL CENTER ₱12,000.00 NA REGULAR
MOTHER THERESA OF CALCUTTA
5/1/2009 11/2/2009 MEDICAL TECHNOLOGIST ₱9,000.00 NA PROBATIONARY
MEDICAL CENTER
OUR LADY OF LOURDES
7/5/2009 4/30/2009 MEDICAL TECHNOLOGIST ₱16,000.00 NA REGULAR
HOSPITAL,STA. MESA
 (Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 20
 LICENSE (if applicable)

Date of
Validity

9/13/2000

arate sheet if necessary)

GOV'T
SERVICE

(Y/
N)
Y

N
arate sheet if necessary)

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) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To
HIV Proficiency Training for Medical Technologists 03/25/2019 03/29/2019 40 HOURS TECHNICAL DEPARTMENT OF HEALTH
PHILIPPINE ASSOCIATION OF
Setting New Vison Beyond Borders 12/04/2018 12/04/2018 8 HOURS TECHNICAL
MEDICAL TECHNOLOGIST
PHILIPPINE ASSOCIATION OF
Current Topics on Microbial Immunology and Pathogenesis 07/14/2018 07/14/2018 8 HOURS TECHNICAL
MEDICAL TECHNOLOGIST
PHILIPPINE ASSOCIATION OF
Raising the Gold Standard for World-Class Medical Technologists 11/22/2017 11/22/2017 8 HOURS TECHNICAL
MEDICAL TECHNOLOGIST
PHILIPPINE ASSOCIATION OF
Quality Improvement in Sediments Exam of Urine 09/09/2017 09/09/2017 8 HOURS TECHNICAL
MEDICAL TECHNOLOGIST
PHILIPPINE ASSOCIATION OF
Interactive Seminar/Workshop in Transfusion Medicine 07/01/2017 07/01/2017 8 HOURS TECHNICAL
MEDICAL TECHNOLOGIST
PHILIPPINE ASSOCIATION OF
Bridging Tradition and Automation: The Power of Platelet estimation Factor 06/19/2017 06/19/2017 8 HOURS TECHNICAL
MEDICAL TECHNOLOGIST
PHILIPPINE ASSOCIATION OF
EMPOWERING MEDICAL TECHNOLOGIST TOWARDS GLOBAL ADVANCEMENT 11/10/2016 11/10/2016 8 HOURS TECHNICAL
MEDICAL TECHNOLOGIST

REDEFINING THE PROFESSION, RESHAPING THE FUTURE 12/3/2015 12/3/2015 8 HOURS TECHNICAL
DEPARTMENT OF HEALTH
PHILIPPINE ASSOCIATION OF
BIONANOTECHNOLOGY APPLICATION IN MEDICAL DIAGNOSTICS 11/14/2015 11/14/2015 4 HOURS TECHNICAL
MEDICAL TECHNOLOGIST

ORIENTATION ON INFECTIOUS DISEASES 6/25/2015 6/25/2015 8 HOURS TECHNICAL

DEPARTMENT OF HEALTH
PHILIPPINE ASSOCIATION OF
50TH PAMET ANNUAL CONVENTION 12/3/2014 12/3/2014 8 HOURS TECHNICAL
MEDICAL TECHNOLOGIST

HOW TO ENSURE EXCELLENT EQAS RESULTS/ EQAS INTERPRETATIONS 3/6/2014 3/6/2014 8 HOURS TECHNICAL
LIFELINE DIAGNOSTICS SUPPLIES, IN
PHILIPPINE ASSOCIATION OF
49TH ANNUAL PAMET CONVENTION 12/4/2013 12/4/2013 8 HOURS TECHNICAL
MEDICAL TECHNOLOGIST
ORIENTATION ON NATIONAL EXTERNAL QUALITY ASSURANCE SURVEY OF
10/11/2012 10/11/2012 8 HOURS TECHNICAL
CLINICAL LABORATORY FOR MED.TECH. DEPARTMENT OF HEALTH

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32.
(Write in full) (Write in
full)
PHILIPPINE ASSOCIATION OF
MICROSOFT WORD, EXCEL PROFICIENT NA MEDICAL TECHNOLOGIST

HIV TESTING PROFICIENT

(Continue on separate sheet if necessary)

SIGNATURE DATE 10/04/2019

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:

________________________________

a. Have you ever been found guilty of any administrative offense? YES ✘ NO
35.

If YES, give details:

________________________________
________________________________
YES ✘ NO
b. Have you been criminally charged before any court?
If YES, give details:
________________________________
Date Filed:
________________________________
Status of Case/s:
YES ✘ NO
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:
________________________________
________________________________
YES ✘ NO

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? ________________________________
RESIGNATION
✘ YES NO
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? YES If YES, give details:
✘ NO

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? YES If YES, give details:
✘ NO

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
YES ✘ NO
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?
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
KALAYAAN VILLAGE , CITY OF SAN the last 6 months
DR.ANTONIO B. ONG,MD MHA FERNANDO PAMPANGA
9195163331 3.5 cm. X 4.5 cm
(passport size)
CABAMBANGAN BACOLOR
LISA S. GRANDA, RMT PAMPANGA
9088880821 With full and handwritten
name tag and signature over
printed name
RINA S. MATIC, RMT CITY OF SAN FERNANDO PAMPANGA 9168762770
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.: 039950

Signature (Sign inside the box)
10/04/2019
Date/Place of Issuance: 09/09/2015 MANILA
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 4