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 ARROJADO
NAME EXTENSION (JR., SR)
FIRST NAME GABRIELLE

MIDDLE NAME SANGRIA

3. DATE OF BIRTH
3/23/1998 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH BACOLOD CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS LOT 11, BLOCK 8 MOUNT LOGAN
House/Block/Lot No. Street
Separat
Widowed MONTEBELLO BATA
Other/s: ed Subdivision/Village Barangay
BACOLOD NEGROS OCCIDENTAL
7. HEIGHT (m) 1.58
City/Municipality Province
8. WEIGHT (kg) 57 ZIP CODE 6100

18. PERMANENT ADDRESS LOT 11, BLOCK 8 MOUNT LOGAN

9. BLOOD TYPE B+
House/Block/Lot No. Street
MONTEBELLO BATA
10. GSIS ID NO. N/A
Subdivision/Village Barangay
BACOLOD NEGROS OCCIDENTAL
11. PAG-IBIG ID NO. 1212-5960-8773
City/Municipality Province

12. PHILHEALTH NO. 1202-5838-3775 ZIP CODE 6100

13. SSS NO. 0739658244 19. TELEPHONE NO. (034) 708-4847

14. TIN NO. 752-976-320 20. MOBILE NO. +63-917-507-9871

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

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME ARROJADO

NAME EXTENSION (JR., SR)
FIRST NAME JASPER

MIDDLE NAME JAVELONA

25. MOTHER'S MAIDEN NAME

SURNAME SANGRIA

FIRST NAME GRACE LYN

MIDDLE NAME ORTEGA (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

UNIVERSITY OF ST. LA SALLE - INTEGRATED

ELEMENTARY
SCHOOL
ELEMENTARY 2005 2011 2011

UNIVERSITY OF ST. LA SALLE - INTEGRATED

SECONDARY /
VOCATIONAL SCHOOL
HIGH SCHOOL 2011 2015 2015 TOP 3

TRADE
COURSE
COLLEGE SILLIMAN UNIVERSITY BACHELOR OF SCIENCE IN NURSING 2015 2019 2019

GRADUATE STUDIES

(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

NURSE LICENSURE EXAM 83.2% JUNE 2019 CEBU CITY 0917361 3/23/2025

(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
28. INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
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)

3/1/2022 2/28/2023 NURSE VACCINATOR BACOLOD CITY HEALTH OFFICE 9900.00 N/A JOB ORDER Y

9/30/2019 10/30/2021 STAFF NURSE RIVERSIDE MEDICAL CENTER, INC. 9471.25 N/A PERMANENT N

(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 / 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
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

CORONAVIRUS DISEASE 2019 (COVID-19) FOR NURSING PROFESSIONALS 5/29/2020 5/29/2020 1.0 TECHNICAL RIVERSIDE MEDICAL CENTER, INC.

DECODING CODE BLUE: A MEGACODE WORKSHOP 1/22/2020 1/22/2020 8.0 TECHNICAL RIVERSIDE MEDICAL CENTER, INC.

INTRODUCTION TO DRAINS, TUBES, AND CATHETERS 1/16/2020 1/16/2020 8.0 TECHNICAL RIVERSIDE MEDICAL CENTER, INC.

RIVERSIDE MEDICAL CENTER, INC. & PHILIPPINE

BASIC LIFE SUPPORT COURSE 11/23/2019 11/24/2019 16.0 TECHNICAL
HEART ASSOCIATION

LACTATION MANAGEMENT 11/19/2019 11/21/2019 20.0 TECHNICAL RIVERSIDE MEDICAL CENTER, INC.

(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 in
(Write in full)
full)
SILLIMAN UNIVERSITY INTRAMURALS 2018 DANCE SPORT COMPETITION
CRITICAL THINKING SKILLS PHILIPPINE NURSES ASSOCIATION (PNA)
1ST RUNNER UP
SIGMA THETA TAU INTERNATIONAL (STTI)
GOOD THERAPEUTIC COMMUNICATION SKILLS SILLIMAN UNIVERSITY COLLEGE OF NURSING (SUCN) MISS NURSING 2018
HONOR SOCIETY OF NURSING
SILLIMAN UNIVERSITY RENAISSANCE YOUTH
TIME MANAGEMENT SKILLS SILLIMAN UNIVERSITY EDITH CARSON HALL PARADE OF TALENTS CHAMPION 2015
LEADERS FORUM (RYLF)
USLS-IS OUTSTANDING ORGANIZATION AWARD FOR CITIZENS ADVANCEMENT AND SILLIMAN UNIVERSITY COLLEGE OF NURSING
DANCING
DEVELOPMENT TRAINING (CADT) 2015 ASSOCIATION (SUCNA)
READING BOOKS USLS-IS PUBLICATION AWARD FOR ANG LAYAG 2015

TRAVELLING

(Continue on separate sheet if necessary)

SIGNATURE DATE
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? ________________________________
________________________________
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
ANTONIO M. MANSO BACOLOD CITY 0917-705-5995 4.5 cm. X 3.5 cm
(passport size)

NEILCE V. BALONO BACOLOD CITY 0939-913-2946

Computer generated
or photocopied picture
DR. THERESA A. GUINO-O DUMAGUETE CITY 0917-706-0723 is not acceptable

42. 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 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.: 0917361

Signature (Sign inside the box)

Date/Place of Issuance: 07/09/2019, DUMAGUETE 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