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 EBOL
NAME EXTENSION (JR., SR)
FIRST NAME KIM ROSE

MIDDLE NAME SABUCLALAO

3. DATE OF BIRTH
(mm/dd/yyyy) 9/29/1991 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH NABUNTURAN, DAVAO If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS PUROK 3

Widowed Separated House/Block/Lot No. Street
PUALAS
Other/s:
Subdivision/Village Barangay
TUBOD LANAO DEL NORTE
7. HEIGHT (m) 1.49 m
City/Municipality Province
8. WEIGHT (kg) 60 kg ZIP CODE 9209

18. PERMANENT ADDRESS PUROK 3

9. BLOOD TYPE O+
House/Block/Lot No. Street
PUALAS
10. GSIS ID NO.
Subdivision/Village Barangay
TUBOD LANAO DEL NORTE
11. PAG-IBIG ID NO. 1211-3468-5397
City/Municipality Province

12. PHILHEALTH NO. 20259663319 ZIP CODE 9209

13. SSS NO. 08-2493174-0 19. TELEPHONE NO. 0632276931

14. TIN NO. 313-497-539-000 20. MOBILE NO. 09269429561

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) fundelic10@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME EBOL 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME CHRISMHARIEBOY

MIDDLE NAME VICOY

OCCUPATION ELECTRICAL ENGINEER

EMPLOYER/BUSINESS NAME GNPOWER KAUSWAGAN LTD. CO.

BUSINESS ADDRESS TACUB, KAUSWAGAN, LANAO DEL NORTE

TELEPHONE NO. NONE

24. FATHER'S SURNAME SABUCLALAO

NAME EXTENSION (JR., SR)
FIRST NAME ANTONIO

MIDDLE NAME LAGAIT

25. MOTHER'S MAIDEN NAME

SURNAME CADALLO

FIRST NAME SUSAN

MIDDLE NAME AMADA (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
 PEDRO C. BUCA SR. MEMORIAL ELEMENTARY 2ND HONORABLE
ELEMENTARY
SCHOOL
6/8/1998 3/27/2004 2004 MENTION

1ST HONORABLE
SECONDARY
VOCATIONAL / MERCY JUNIOR COLLEGE 6/2/2004 3/26/2008 2008 MENTION

TRADE DBP ENDOWMENT

EDUCATION
COURSE
COLLEGE MINDANAO STATE UNIVERSITY-MARAWI BACHELOR OF SCIENCE IN NURSING 6/9/2008 4/12/2012 2012 PROGRAM
SCHOLARSHIP

MASTER IN NURSING MAJOR IN MATERNAL

GRADUATE STUDIES MISAMIS UNIVERSITY
AND CHILD NURSING
4/20/2015 ### 2016
(Continue on separate sheet if necessary)

SIGNATURE DATE 5/31/2019

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 JUNE 30-JULY 1, CAPITOL UNIVERSITY, CAGAYAN DE ORO
81.4 2012
0774622 9/29/2021
EXAMINATION CITY

(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
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To (Y/
N)
6/7/2018 PRESENT SENIOR TEACHER A 51TALK PHILIPPINES P 14,000 CONTRACTUAL N
DEPARTMENT OF HEALTH REGIONAL
2/10/2017 12/31/2017 NURSE DEPLOYMENT PROJECT P 26, 878.00 15 CONTRACTUAL Y
OFFICE X
DEPARTMENT OF HEALTH REGIONAL
1/18/2016 12/31/2016 NURSE DEPLOYMENT PROJECT P 26, 878.00 15 CONTRACTUAL Y
OFFICE X
DEPARTMENT OF HEALTH REGIONAL
1/12/2015 12/31/2015 NURSE DEPLOYMENT PROJECT P 18, 549.00 11 CONTRACTUAL Y
OFFICE X
1/16/2014 12/31/2014 STAFF NURSE DELBERT JONS POLYCLINIC P 7,000.00 CONTRACTUAL N
REGISTERED NURSES FOR HEALTH DEPARTMENT OF HEALTH REGIONAL
1/14/2013 12/31/2013 P 8,000.00 CONTRACTUAL Y
ENHANCEMENT AND LOCAL SERIVES HEALTH OFFICE-10

(Continue on separate sheet if necessary)

SIGNATURE DATE 5/31/2019

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 WORK
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/ SPONSORED BY
NUMBER OF HOURS
(Write in full) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To

BOOKKEEPING AND BASIC ACOUNTING WORKSHOP 1/22/2019 1/22/2019 9 TECHNICAL HM ACCOUNTING AND BUSINESS SCHOOL

TRAINING OF TRAINERS FOR COMMUNITY BASED REHABILITATION PROGRAM 8/24/2017 8/25/2017 16 TECHNICAL RURAL HEALTH UNIT OF TUBOD

DEPARTMENT OF HEALTH REGIONAL OFFICE

"ENABLING PUROK CHAMPIONS" AMONG NURSES OF LANAO DEL NORTE 9/21/2016 9/23/2016 24 TECHNICAL
X

"GRADUATE SCHOOL RESEARCH COLLOQUIUM" 8/6/2016 8/6/2016 8 TECHNICAL MISAMIS UNIVERISTY GRADUATE SCHOOL

"DOCUMENTATION IN IV THERAPY" ACCREDITED BY ANSAP AS IV UPDATE

6/5/2016 6/5/2016 8 TECHNICAL ILIGAN MEDICAL CENTER HOSPITAL
PROVIDER #212
"INFUSION DEVICE IN IV THERAPY" ACCREDITED BY ANSAP AS IV UPDATE
6/4/2016 6/4/2016 8 TECHNICAL ILIGAN MEDICAL CENTER HOSPITAL
PROVIDER #212
"PAIN MANAGEMENT IN CANCER" ACCREDITED BY ANSAP AS IV UPDATE
6/3/2016 6/3/2016 8 TECHNICAL ILIGAN MEDICAL CENTER HOSPITAL
PROVIDER #212

SEMINAR ON "CREATING FUTURE NURSING LEADERS NOW" 4/2/2016 4/2/2016 8 SUPERVISORY MISAMIS UNIVERISTY GRADUATE SCHOOL

TUBOD MUNICIPAL DISASTER RISK

BASIC LIFE SUPPORT AND FIRST AID TRAINING FOR HEALTH CARE PROVIDERS 2/9/2016 2/12/2016 32 TECHNICAL
REDUCTION AND MANAGEMENT COUNCIL
NURSE DEPLOYMENT PROJECT CAPABILITY BUILDING 2015 "HIGH IMPACT FOR DEPARTMENT OF HEALTH REGIONAL OFFICE
5/4/2015 5/8/2015 40 TECHNICAL
BREAKTHROUGH PROGRAM" X
DEPARTMENT OF HEALTH REGIONAL OFFICE X AND
BARANGAY NUTRITION SCHOLAR TRAINING 3/16/2015 3/18/2015 24 TECHNICAL NATIONAL NUTRITION COUNCIL X

PEN-WHO ORIENTATION SEMINAR 3/3/2015 3/3/2015 8 TECHNICAL RURAL HEALTH UNIT OF TUBOD

REGISTERED NURSES FOR HEALTH ENHANCEMENT AND LOCAL SERVICES DEPARTMENT OF HEALTH REGIONAL HEALTH
1/14/2013 12/31/2013 1920 TECHNICAL
PROJECT OFFICE 10

REGULAR IV TRAINING PROGRAM 10/29/2012 10/31/2012 24 TECHNICAL MINDANAO SANITARIUM AND HOSPITAL

STROKE SOCIETY PHILIPPINES NORTHERN MINDANAO

13TH ANNUAL CONVENTION OF THE STROKE SOCIETY OF THE PHILIPPINES 8/9/2012 8/11/2012 24 TECHNICAL CHAPTER AND MISAMIS ORIENTAL MEDICAL SOCIETY

UNIVERSITY OF THE PHILIPPINES ALUMNI ASSOCIATION

FOURTH AND HEALTH WELLNESS SEMINAR 6/16/2011 6/16/2011 8 TECHNICAL MINDANAO STATE UNIVERSITY MARAWI CHAPTER

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33. (Write
(Write in full)
in full)
CERTIFICATE OF RECOGNITION FOR AN EXEMPLARY ACHIEVEMENT ON THE
RHYMTHMIC GYMNASTICS PHILIPPINE NURSES ASSOCIATION
HARMONIZED MASS DRUG ADMINISTRATION
BEST IN RESEARCH STUDY " SOCIAL SUPPORT AMONG PREGNANT TEENAGERS
MINDANAO STATE UNIVERSITY MARAWI
DANCING OF TUBOD, LANAO DEL NORTE: ASSESSMENT ON EMOTIONAL AND
ALUMNI ASSOCIATION
INFORMATIONAL SUPPORT
BEST IN COMMUNITY SERVICE WHO HAVE TRULY MADE A DIFFERENCE FOR THE COLLEGE OF HEALTH SCIENCES ALUMNI
COOKING
COMMUNITY IN HEALTH SERVICE THROUGH TEAMWORK AND COLLABORATION ASSOCIATION
CERTIFICATE OF RECOGNITION FOR ACHIEVING 90% ACCOMPLISHMENT RATE ON DBP ENDOWMENT EDUCATION PROGRAM
BAKING
THE PRENATAL INDICATOR IN HER RESPECTIVE AREA OF RESPONSIBILITY SCHOLARS' ALUMNI ASSOCIATION

(Continue on separate sheet if necessary)

SIGNATURE DATE 5/31/2019

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 ✘
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘
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 within
the last 6 months
MELANIA F. ABAD-UNTAO, MD, MPH PRINCESA, BAROY,LANAO DEL NORTE 9166919515 3.5 cm. X 4.5 cm
(passport size)
POBLACION, TUBOD, LANA DEL
MARIA FILIPINA C. CAMINS, MD NORTE
9177124211 With full and handwritten
name tag and signature over
POBLACION, TUBOD, LANAO DEL printed name
FLORE T. ROM, RN NORTE
9054971879
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

ID/License/Passport No.: 0774622

Signature (Sign inside the box)

Date/Place of Issuance: 09/05/2012/CAGAYAN DE ORO CITY

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