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 LOMONDAYA
NAME EXTENSION (JR., SR) N/A
FIRST NAME SHAHANA

MIDDLE NAME KASIM

3. DATE OF BIRTH
JUNE 14, 1995 16. CITIZENSHIP Filipino Dual Citizenship
(mm/dd/yyyy) ✘
by
by naturalization
birth
4. PLACE OF BIRTH COTABATO 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 N/A N/A

Widowed House/Block/Lot No. Street
Separated NOTRE DAME VILLAGE ROSARY HEIGHTS 8
Other/s:
Subdivision/Village Barangay
COTABATO CITY MAGUINDANAO
7. HEIGHT (m) 1.53
City/Municipality Province

8. WEIGHT (kg) 54kg ZIP CODE 9600

9. BLOOD TYPE B+ 18. PERMANENT ADDRESS N/A N./A

House/Block/Lot No. Street

10. GSIS ID NO. N/A NOTRE DAME VILLAGE ROSARY HEIGHTS 8

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121266953441 COTABATO CITY MAGUINDANAO

City/Municipality Province

12. PHILHEALTH NO. 20-025071953-8 ZIP CODE 9600

13. SSS NO. N/A 19. TELEPHONE NO. N/A

14. TIN NO. 714-921-323 20. MOBILE NO. 09058612654

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) shanana@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) N/A
FIRST NAME N/A 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 LOMONDAYA

NAME EXTENSION (JR., SR) N/A
FIRST NAME SAMAD

MIDDLE NAME HASSIM

25. MOTHER'S MAIDEN NAME VILMA LUMIMBANG KASIM

SURNAME KASIM

FIRST NAME VILMA

MIDDLE NAME LUMIMBANG (Continue on separate sheet if necessary)

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

ELEMENTARY ELEMENTARY LEARNING CENTER ELEMENTARY 2002 2008 N/A 2008 1st HONOR

VOCATIONAL
SECONDARY / NOTRE DAME OF COTABATO HIGH SCHOOL 2008 2012 N/A 2012 N/A

DATU IBRAHIM PAGLAS MEMORIAL

DIPLOMA IN MIDWIFERY 2014 2016 N/A 2014 N/A
COLLEGE

COLLEGE
TRADE COURSE UNIVERSITY OF SOUTHERN MINDANAO BACHELOR OF SCIENCE IN MIDWIFERY 2012 2017 N/A 2017 N/A

SAINT BENEDICT COLLEGE OF

GRADUATE STUDIES MASTER IN PUBLIC ADMINISTRATION 2019 2021 N/A N/A N/A
COTABATO
(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) LICENSE (if applicable)
DATE OF
UNDER SPECIAL LAWS/ CES/ CSEE RATING
EXAMINATION / PLACE OF EXAMINATION / CONFERMENT Date of
BARANGAY ELIGIBILITY / (If Applicable) NUMBER
CONFERMENT Validity
DRIVER'S LICENSE
RA 1080 (MIDWIFERY LICENSURE
81.00% JUNE 11-12, 2019 DAVAO CITY 33819382 1/23/2025
EXAMINATION)

CAREER SERVICE EXAM (PROFESSIONAL) 80.22% AUGUST 6-7, 2017 KORONADAL CITY, SOUTH COTABATO N/A N/A

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE GOV'T
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experience sheet. SERVICE
SALARY/
JOB/ PAY
28. INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY applicable)& STATUS OF
(Write STEP
SALARY APPOINTMENT
From To (Write in full/Do not abbreviate) in full/Do not abbreviate) (Format "00-
0")/
INCREMENT
MINISTRY OF HEALTH-BARMM, INTEGRATED PROVINCIAL CONTRACT OF
01/01/2022 PRESENT MIDWIFE II 35,000.00 N/A NO
HEALTH OFFICE-MAGUINDANAO SERVICE (Y/ N)
MINISTRY OF HEALTH-BANGSAMORO AUTONOMOUS CONTRACT OF
10/01/2020 12/31/2021 MIDWIFE II REGION IN MUSLIM MINDANAO
35,000.00 N/A NO
SERVICE
MINISTRY OF HEALTH-BANGSAMORO AUTONOMOUS CONTRACT OF
01/02/2020 09/31/2020 ADMINISTRATIVE AIDE REGION IN MUSLIM MINDANAO
12000.00 N/A NO
SERVICE
MINISTRY OF HEALTH-BANGSAMORO AUTONOMOUS CONTRACT OF
01/01/2019 12/31/2019 ADMINISTRATIVE AIDE REGION IN MUSLIM MINDANAO
10000.00 N/A NO
SERVICE
DEPARTMENT OF HEALTH-AUTONOMOUS REGION CONTRACT OF
10/02/2017 12/31/2018 ADMINISTRATIVE AIDE 8000.00 N/A NO
IN MUSLIM MINDANAO 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
NAME & ADDRESS OF ORGANIZATION
29. NUMBER
(Write in full) POSITION / NATURE OF WORK
(mm/dd/yyyy) OF HOURS
From To

DATU IBRAHIM PAGLAS MEMORIAL COLLEGE 07/01/2017 PRESENT N/A COLLEGE INSTRUCTOR

(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 NUMBER ( Managerial/ CONDUCTED/ SPONSORED BY
PROGRAMS (Write in full) OF HOURS Supervisory/ (Write in full)
(mm/dd/yyyy) Technical/etc)
From To
HUMAN RESOURCE MANAGEMENT PRACTITIONER'S
KNOWLEDGE SHARING SERIES 10/04/2022 10/06/2022 24.0 TECHNICAL
COUNCIL
PILOT TESTING ON NEW STAFF ORIENTATION 06/13/22 06/14/22 16.0 TECHNICAL JAPAN INTERNATIONAL COOPERATION AGENCY

TRAINING-WORKSHOP ON CITIZEN'S CHARTER FORMULATION AND

05/16/22 05/20/22 40.0 TECHNICAL DEVELOPMENT ACADEMY OF THE PHILIPPINES
ENHANCEMENT

WRITESHOP ON THE FORMULATION OF MERIT SELECTION PLAN AND STRATEGIC

PERFORMANCE MANAGEMENT SYSTEM POLICY
03/28/22 04/01/22 32.0 MANAGERIAL CIVIL SERVICE COMMISSION FOR BARMM

CENTER FOR HUMAN RESEARCH AND DEVELOPMENT

INTERNATIONAL SEMINAR WORKSHOP ON TRANSFORMATIONAL 11/27/2021 12/04/2021 24.0 TECHNICAL
FOUNDATION, INC.
LEADERSHIP: DEVELOPING A GROWTH ORIENTED WORKPLACE CULTURE
ORIENTATION ON RECRUITMENT PROCEDURES IN THE GOVERNMENT
09/07/2021 09/08/2021 16.0 TECHNICAL CIVIL SERVICE COMMISSION FOR BARMM
SERVICE

TRIAL TRAINING ON THE CREATION OF HANDBOOK FOR NEW STAFF

07/05/2021 07/06/2021 16.0 TECHNICAL JAPAN INTERNATIONAL COOPERATION AGENCY
ORIENTATION
DIALOGUE AND ORIENTATION ON OMNIBUS RULES ON APPOINTMENTS
01/08/2021 01/08/2021 4.0 TECHNICAL CIVIL SERVICE COMMISSION FOR BARMM
AND OTHER HUMAN RESOURCE ACTIONS
ONLINE ORIENTATION FOR HANDBOOK CREATION AND NEW ENTRANTS
12/2/2020 12/03/2020 16.0 TECHNICAL JAPAN INTERNATIONAL COOPERATION AGENCY
ORIENTATION

REVISED 2017 OMNIBUS RULES ON APPOINTMENTS, 2017 RULES ON

ADMINISTRATIVE CASES IN THE CIVIL SERVICE, AND LEAVE ADMINISTRATION 10/21/2019 10/25/2021 40.0 TECHNICAL CIVIL SERVICE COMMISSION FOR BARMM
COURSE FOR EFFECTIVENESS

PERSONNEL OFFICERS ASSOCIATION OF THE

TRAINING/WORKSHOP ON WORK-LIFE FLEXIBILITY 10/22/2019 10/25/2019 32.0 TECHNICAL
PHILIPPINES
PERSONNEL OFFICERS ASSOCIATION OF THE
TRAINING/WORKSHOP ON ACCOUNTING FOR NON-ACCOUNTANTS 07/23/2019 07/26/2019 32.0 TECHNICAL
PHILIPPINES
DEPARTMENT OF HEALTH CENTRAL OFFICE-
ONLINE DOCUMENT TRACKING INFORMATION SYSTEM TRAINING AND
10/17/2018 10/18/2018 16.0 TECHNICAL KNOWLEDGE MANAGEMENT AND INFORMATION
ORIENTATION
TECHNOLOGY SERVICE

ARMM MSME SUMMIT 2017 12/12/2017 12/12/2017 8.0 TECHNICAL DEPARTMENT OF TRADE AND INDUSTRY-ARMM

(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)

INTEGRATED MIDWIVES ASSOCIATION OF THE

COMPUTER LITERATE N/A
PHILIPPINES

ORGANIZING

SINGING

(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 ✘ 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
DR. KADIL M. SINOLINDING COTABATO CITY 09554345455 3.5 cm. X 4.5 cm
(passport size)

ABDULGANI M. PACASIRANG, JD COTABATO CITY 09175492853 With full and handwritten

name tag and signature over
printed name
SHIEKH KHALIFA U. NANDO DATU PAGLAS, MAGUINDANAO 09382713225
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.: 443235

Signature (Sign inside the box)

Date/Place of Issuance: FEBRUARY 2018/COTABATO 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