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

MIDDLE NAME MONTEZA

3. DATE OF BIRTH
8/25/1995 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH UPPER TOMINOBO PUROK 7 ILIGAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

Single Married 17. RESIDENTIAL ADDRESS

6 CIVIL STATUS ✘
House/Block/Lot No. Street
Widowed Separated
NATIONAL HIGHWAY KILALA
Other/s: Subdivision/Village Barangay
MARAWI CITY LANAO DEL SUR
7. HEIGHT (m) 5'2
City/Municipality Province
8. WEIGHT (kg) "65" ZIP CODE 9700

18. PERMANENT ADDRESS

9. BLOOD TYPE "O"
House/Block/Lot No. Street
NATIONAL HIGHWAY KILALA
10. GSIS ID NO. N/A
Subdivision/Village Barangay
LANAO DEL SUR
11. PAG-IBIG ID NO. N/A
City/Municipality Province

12. PHILHEALTH NO. 202015164583 ZIP CODE 9700

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

14. TIN NO. 762-934-369 20. MOBILE NO.

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) nolskee9010@gmail.com

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME MACABANDING 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) N/A MOH'D BINNNOUR D. MACABANDING
FIRST NAME ANSANO 4/30/2012

MIDDLE NAME MEJARIS MOH'JANATE D. MACABANDING 10/10/2014

OCCUPATION DRIVER JOHAIRIAH D. MACABANDING 4/10/2016

EMPLOYER/BUSINESS NAME NOROLYAQEEN D. MACABANDING 7/14/2019

BUSINESS ADDRESS JOHARAH D. MACABANDING 9/1/2020

TELEPHONE NO. JORRAH D. MACABANDING 7/17/2022

24. FATHER'S SURNAME DISOMIMBA

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

MIDDLE NAME TECSON

25. MOTHER'S MAIDEN NAME MONTEZA

SURNAME DISOMIMBA

FIRST NAME CELINA

MIDDLE NAME MONTEZA (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 SENATOR NINOY AQUINO COLLEGE FOUNDATION 2009 2010 2010 N/A

SECONDARY /
VOCATIONAL MARAWI CAPITOL COLLEGE FOUNDATION 2015 2016 2016

TESDA HOUSEKEEPING NC II

TRADE
COURSE
COLLEGE N/A

GRADUATE STUDIES N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE January 15, 2024

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.
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)

12/31/2023 PRESENT INSTITUTIONAL WORKER AMAI PAKPAK MEDICAL CENTER 12,100.00 N/A JOB ORDER

1/28/2023 12/31/2023 INSTITUTIONAL WORKER AMAI PAKPAK MEDICAL CENTER 12,100.00 N/A JOB ORDER

1/28/2022 1/1/2023 INSTITUTIONAL WORKER AMAI PAKPAK MEDICAL CENTER 12,100.00 N/A JOB ORDER

1/28/2021 1/1/2022 INSTITUTIONAL WORKER AMAI PAKPAK MEDICAL CENTER 12,100.00 N/A JOB ORDER

1/28/2010 1/1/2021 INSTITUTIONAL WORKER AMAI PAKPAK MEDICAL CENTER 9,900.00 N/A JOB ORDER

1/28/2019 1/1/2010 INSTITUTIONAL WORKER AMAI PAKPAK MEDICAL CENTER 7,700.00 N/A JOB ORDER

1/28/2018 1/28/2019 INSTITUTIONAL WORKER AMAI PAKPAK MEDICAL CENTER 6,160.00 N/A JOB ORDER

(Continue on separate sheet if necessary)

SIGNATURE DATE January 15, 2024

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

(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

HOUSEKEEPING NC II 11/12/2020 11/12/2025 5HOURS TECHNICAL TESDA,DITUCALAN ILIGAN CITY

LECTURE AND ORIENTATION ON PATIENT SAFETY,OCCUPATIONAL SAFETY AND

11/29/2023 5HOURS TECHNICAL AMAI PAKPAK MEDICAL CENTER
INFECTION PREVENTION AND CONTROL

BASEC LIFE SUPPORT-CARDIOPULMONARY RESUSCITATION 1/5/2024 3HOURS TECHNICAL

AMAI PAKPAK MEDICAL CENTER

(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)

(Continue on separate sheet if necessary)

SIGNATURE DATE January.15.2024

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: MARANAO
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
JOHANA MONTEZA KILALA MARAWI CITY 9663668377 3.5 cm. X 4.5 cm
(passport size)

RASHMIA ABBAS,RN,MAN AMAI PAKPAK MEDICAL CENTER 9666210348 With full and handwritten
name tag and signature over
printed name

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:

ID/License/Passport No.:
Signature (Sign inside the box)
January 15 2024
Date/Place of Issuance: 12/15/2015 DFA CAGAYAN DE ORO
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this 10th of January 2023 , affiant exhibiting his/her validly issued government ID as indicated above.

ATTY. ESNIHAIRAH M. DISANGCOPAN, SH.L

Attorney IV
Person Administering Oath

CS FORM 212 (Revised 2017), Page 4 of 4