CS Form No.

212
Revised 2017
PERSONAL DATA SHEET
W AR N IN G : An y m is re p re s e n ta tio n m a d e in th e P e rs o n a l D a ta S h e e t a n d th e W o rk E x p e rie n c e S h e e t s h a ll c a u s e th e filin g o f a d m in is tra tiv e /c rim in a l c a s e /s a g a in s t th e p e rs o n
c o n c e rn e d .
R E AD T H E AT T AC H E D G U ID E T O F IL L IN G O U T T H E P E R S O N AL D AT A S H E E T (P D S ) B E F O R E AC C O M P L IS H IN G T H E P D S F O R M .
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 AÑONUEVO
NAME EXTENSION (JR., SR)
FIRST NAME EDUARDO

MIDDLE NAME MACATANGAY

3. DATE OF BIRTH
(mm/dd/yyyy)
05/18/1983 16. CITIZENSHIP Filipino Dual Citizenship
by birth by naturalization

4. PLACE OF BIRTH LOBO, BATANGAS If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female

Single Married 17. RESIDENTIAL ADDRESS 160 CAPT RILLO ST

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
GARITA A
Other/s:
Subdivision/Village Barangay
MARAGONDON CAVITE
7. HEIGHT (m) 1.80
City/Municipality Province
8. WEIGHT (kg) 105 ZIP CODE

18. PERMANENT ADDRESS 160 CAPT RILLO ST

9. BLOOD TYPE O+
House/Block/Lot No. Street
GARITA A
10. GSIS ID NO.
Subdivision/Village Barangay

11. PAG-IBIG ID NO.

MARAGONDON C A V IT E
City/Municipality Province

12. PHILHEALTH NO. ZIP CODE 4112

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 405 - 095 - 054 20. MOBILE NO. 09175529248

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) EBBOYMD@GMAIL,COM
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME AÑONUEVO CHILDREN DATE OF BIRTH (mm/dd/yyyy)

/ FIRST NAME JANICE

NAME EXTENSION (JR., SR) ELYZZA JAN MARIE URETA AÑONUIEVO 07/07/2007

MIDDLE NAME URETA ELYSSE JADE MARIE URETA AÑONUIEVO 05/18/2012

OCCUPATION DOCTOR
EMPLOYER/BUSINESS NAME PRIVATE PRACTICE
BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME AÑONUEVO

NAME EXTENSION (JR., SR)
FIRST NAME EDMUNDO
MIDDLE NAME GOMEZ
25. MOTHER'S MAIDEN NAME AURELIA CLOSA MACATANGAY
SURNAME AÑONUEVO
FIRST NAME AURELIA
MIDDLE NAME MACATANGAY (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

SCHOLARSHIP/
26. PERIOD OF ATTENDANCE HIGHEST LEVEL/
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE YEAR ACADEMIC
LEVEL UNITS EARNED
(Write in full) (Write in full) (if not graduated)
GRADUATED HONORS
From To RECEIVED

ELEMENTARY WESTERN PHILIPPINE COLLEGES BASIC EDUCATION 1996

 WITH
SECONDARY ST BRIDGET COLLEGE BASIC EDUCATION 2000
HONORS
VOCATIONAL /
TRADE COURSE

COLLEGE BATANGAS STATE UNIVERSITY BS BIOLOGY 2004 CUM LAUDE

GRADUATE STUDIES PAMANTASAN NG LUNGSOD NG MAYNILA DOCTOR OF MEDICINE 2008

(Continue on separate sheet if necessary)

SIGNATURE DATE
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

(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.
INCLUSIVE DATES SALARY/ JOB/ PAY
28. GRADE (if GOV'T
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY STATUS OF
applicable)& STEP SERVICE
(Write in full/Do not abbreviate) (Write in full/Do not abbreviate) SALARY (Format "00-0")/
APPOINTMENT
(Y/ N)
From To INCREMENT
 (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
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29.
(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 Type of LD

30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full) (Write in full)
 (Continue on separate sheet if necessary)

SIGNATURE DATE
C S FO R M 212 (R evised 2017), P age 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?
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
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten

name tag and signature over
printed name
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and Computer generated
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the or photocopied picture
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:

ID/License/Passport No.:
Signature (Sign inside the box)

Date/Place of Issuance:
Date/Place of Issuance:
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