CS FORM 212 (Revised 2005

)

PERSONAL DATA SHEET
Print legibly. Mark appropriate boxes

q with "P" and use separate sheet if necessary.

1. CS ID No.

(to be filled up by CSC)

I. PERSONAL INFORMATION
2. SURNAME FIRST NAME MIDDLE NAME GUMIRAN SHAY ANN JUAN 07/01/1987 TUGUEGARAO, CAGAYAN 16. RESIDENTIAL ADDRESS 3. NAME EXTENSION (e.g. Jr., Sr.)

4. DATE OF BIRTH (mm/dd/yyyy) 5. PLACE OF BIRTH 6. SEX 7. CIVIL STATUS

131-B ARELLANO EXT., UGAC SUR TUGUEGARAO CITY 3500 304-0584

Male Single

Fem ale

q Widowed ZIP CODE q Separated Married 17. TELEPHONE NO. q q Annulled Others, specify ___________ PERMANENT ADDRESS 18.
FILIPINO 1.56 42kgs. "O" NONE NONE NONE NONE NONE NONE
ZIP CODE 19. TELEPHONE NO.

8. CITIZENSHIP 9. HEIGHT (m) 10. WEIGHT (kg) 11. BLOOD TYPE 12. GSIS ID NO. 13. PAG-IBIG ID NO. 14. PHILHEALTH NO. 15. SSS NO.

131-B ARELLANO EXT., UGAC SUR TUGUEGARAO CITY 3500 304-0584

shayn_4327@yahoo.com 20. E-MAIL ADDRESS (if any)
21. CELLPHONE NO. (if any) 22. AGENCY EMPLOYEE NO. 23. TIN

09272301245

NONE NONE

II. FAMILY BACKGROUND
24.SPOUSE'S SURNAME FIRST NAME 25. NAME OF CHILD (Write full name and list DATE OF BIRTH (mm/dd/yyyy) all)

MIDDLE NAME ONE N OCCUPATION

NA

/ / / / /

/ / / / /

EMPLOYER/BUS. NAME A N BUSINESS ADDRESS TELEPHONE NO.

NA NONE

(Continue on separate sheet if necessary) 26. FATHER'S SURNAME FIRST NAME MIDDLE NAME

GUMIRAN DEMETRIO DARISAN / / / / / /

27. MOTHER'S MAIDEN NAME SURNAME FIRST NAME MIDDLE NAME

JUAN ANITA CUZZAMU
YEAR GRADUATE D DEGREE COURSE (Write in full)

/
(Continue on separate sheet if necessary)

/

III. EDUCATIONAL BACKGROUND
28. LEVEL NAME OF SCHOOL (Write in full) TUGUEGARAO WEST CENTRAL ELEMENTARY SCHOOL UNIVERSITY OF SAINT LOUIS TUGUEGARAO

ELEMENTARY

(if 2000 graduated )
2004

HIGHEST GRADE/ LEVEL/ UNITS EARNED (if not graduated)

INCLUSIVE DATES OF ATTENDANCE From 1994 To 2000

SCHOLARSHIP/ ACADEMIC HONORS RECEIVED

SECONDARY VOCATIONAL/ TRADE COURSE TERTIARY

2000

2004

ST. PAUL UNIVERSITY PHILIPPINES

ASSOCIATE IN HEALTH SCIENCE EDUCATION BACHELOR OF SCIENCE IN NURSING

2004

2006

PINES CITY COLLEGES

2008

2006

2008

GRADUATE STUDIES

(Continue on separate sheet if necessary) Page 1 of 4

Page 2 of 4 . INCLUSIVE DATES (mm/dd/yyyy) From To POSITION TITLE (Write in full) DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY (Write in SALARY full) SALARY GRADE & STATUS OF STEP APPOINTMEN INCREMENT T (Format "000") GOV'T SERVICE (Yes / No) (Continue on separate sheet if necessary) CS FORM 212 (Revised 2005).00% TUGUEGARAO CITY (Continue on separate sheet if necessary) V. Start from your current work) 30.IV. WORK EXPERIENCE (Include private employment. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEE RATING DATE OF EXAMINATIO N/ CONFERMENT 06/0607/2009 LICENSE (if applicable) PLACE OF EXAMINATION / CONFERMENT NUMBER 0580378 DATE OF RELEASE 11/09/20 09 NURSING LICENSURE EXAMINATION 75. CIVIL SERVICE ELIGIBILITY 29.

VI. NAME & ADDRESS OF ORGANIZATION (Write in full) (mm/dd/yyyy) From To / / / / / / / / / / / / / / / / / / / / NUMBER OF HOURS POSITION / NATURE OF WORK (Continue on separate sheet if necessary) VII. NON-ACADEMIC DISTINCTIONS / RECOGNITION: (Write in full) 35.MPh PHILIPPINE NATIONAL REDCROSS (CAGAYAN CHAPTER) PHILIPPINE NATIONAL REDCROSS (CAGAYAN CHAPTER) 07/21/2007 03/08/2008 09/27/2009 04/12/2010 04/16/2010 (Continue on separate sheet if necessary) VIII.) 32. TRAINING PROGRAMS (Start from the most recent training. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write in full) INCLUSIVE DATES OF ATTENDANCE From ADVANCE COMMUNITY NURSING PRACTICE USING IMCI PERSPECTIVE THIRD CORDILLERA STUDENT NURSES' CONGRESS SAFE NURSING PRACTICE FIRST AID TRAINING (STANDARD) BASIC LIFE SUPPORT (CPR TRAINING FOR HEALTHCARE PROVIDER) (mm/dd/yyyy) To 07/21/2007 03/08/2008 09/27/2009 04/15/2010 04/17/2010 NUMBER OF HOURS 2 5 4 32 16 CONDUCTED/ SPONSORED BY (Write in full) JEROME B. Page 3 of 4 . MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full) COMPUTER LITERATE (Continue on separate sheet if necessary) CS FORM 212 (Revised 2005).MAN.PhD HILDEGARDA HIPOLITO RN. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S INCLUSIVE DATES 31. OTHER INFORMATION 33.MSN. SPECIAL SKILLS / HOBBIES: 34. MANSIBANG MARY GRACE LACANARIA RN.

(b) Magna Carta for Disabled Persons (RA 7277). REFERENCES (Person not related by consanguinity or affinity to applicant / appointee) NAME VICTORIA B. NO. end of term. correct and complete statement pursuant to the provisions of pertinent laws. 03148148 COMMUNITY TAX CERTIFICATE NO. give details: ________________________________ ________________________________ b. termination. Have you ever been formally charged?  YES NO If YES.36. give details: ____________________________________ _ ____________________________________ _ YES  NO ____________________________________ If _ YES. Have you ever been guilty of any administrative offense? 38. decree. in the public or private sector? 40. b. BAWAYAN JUANITA Y.5 X 4. please specify: ____________________  NO  NO  NO  NO  NO N O NO  declare under oath that this Personal Data Sheet has been accomplished by me. dropped from the rolls. chief of office/bureau/department or person who has immediate supervision over you in the Office. dismissal. please specify: ____________________ If YES. I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust that this information shall remain confidential. Have you ever been convicted of any crime or violation of any law. give details: ________________________________ ________________________________ If YES. please specify: ____________________ If YES. AWOL or phased out. Are you related by consanguinity or affinity to any of the following : a. Within 37 a. finished contract.5 cm If YES. Page 4 of 4 . ordinance or regulation by any court or tribunal? 39. recommending authority. I ADDRESS PCC BAGUIO CITY PCC BAGUIO CITY TCPGH TUGUEGARAO CITY  YES  YES  YES  YES  YES YES  YES  If YES. 2010 DATE ACCOMPLISHED RIGHT THUMBMARK PHOTO CS FORM 212 (Revised 2005). and is a true. Pursuant to: (a) Indigenous People's Act (RA 8371). TUGUEGARAO CITY ISSUED AT 08/06/2010 ISSUED ON (mm/dd/yyyy) SIGNATURE (Sign inside the box) August 6. give details: ________________________________ ________________________________ If YES. NIALLA JANE TAMARAY 43. please answer the following items: Are you a member of any indigenous group? Are you differently abled? Are you a solo parent? a. 42. rules and regulations of the Republic of the Philippines. Within the third degree (for National Government Employees): appointing authority. c. retirement. Bureau or Department where you will be appointed? the fourth degree (for Local Government Employees): appointing authority or recommending authority where you will be appointed? b. give details: ____________________________________ _ ____________________________________ _ ____________________________________ YES NO _ If YES. give details: ________________________________ ________________________________ If YES. Have you ever been separated from the service in any of the following modes: resignation. ID picture taken within the last 6 months 3. give details: ________________________________ ________________________________ TEL. Have you ever been a candidate in a national or local election (except Barangay election)? 41. and (c) Solo Parents Welfare Act of 2000 (RA 8972).