CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any representation 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 BASCARA
FIRST NAME JORMIAH NAME EXTENSION (JR., SR) N/A

MIDDLE NAME URANGGAGA

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 01/06/1992 ✘ Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH DITSAAN RAMAIN, LANAO DEL SUR 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
Separat House/Block/Lot No. Street
Widowed N/A DARIMBANG
Other/s: ed
Subdivision/Village Barangay

7. HEIGHT (m) 1.58 DITSAAN RAMAIN LANAO DEL SUR

City/Municipality Province
8. WEIGHT (kg) 54 ZIP CODE 9713

9. BLOOD TYPE "O"

18. PERMANENT ADDRESS N/A N/A
House/Block/Lot No. Street

10. GSIS ID NO. N/A N/A DARIMBANG

Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A DITSAAN RAMAIN LANAO DEL SUR

City/Municipality Province

12. PHILHEALTH NO. 200250252640 ZIP CODE 9713

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

14. TIN NO. 950806647 20. MOBILE NO. 9482001336

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

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME BASCARA (DECEASED)

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

MIDDLE NAME URANGGAGA

25. MOTHER'S MAIDEN NAME PINDO RAHIM URANGGAGA
SURNAME URANGGAGA
FIRST NAME PINDO
MIDDLE NAME RAHIM (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

SULTAN ALAUYA ALONTO CENTRAL WITH

ELEMENTARY ELEMENTARY 1998 2003 GRADUATED 2003
ELEMENTARY SCHOOL HONOR
ADIONG MEMORIAL POLYTECNIC
SECONDARY
VOCATIONAL / HIGH SCHOOL 2003 2007 GRADUATED 2007 N/A
STATE COLLEGE

N/A
TRADE
COURSE JAMIATU MARAWI AL-ISLAMIA BACHELOR OF SCIENCE IN
COLLEGE 2007 2011 GRADUATED 2011 N/A
FOUNDATION NURSING

GRADUATE STUDIES N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE July 29, 2019

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL DATE OF LICENSE (if applicable)
RATING
LAWS/ CES/ CSEE BARANGAY EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity
R.A. 1080 PHILIPPINE NURSING LICENSURE
76.40% JULY 2011 CAGAYAN DE ORO CITY 748849 01/06/2021
EXAMINATION
R.A. 1080 PHILIPPINE MIDWIFERY LICENSURE
82.30% APRIL 2017 CAGAYAN DE ORO CITY 174066 01/06/2023
EXAMINATION

(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 SERVICE
28. INCLUSIVE DATES SALARY/ JOB/ PAY
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) STATUS OF
(Write in full/Do not (Write MONTHLY SALARY applicable)& STEP
APPOINTMENT
abbreviate) in full/Do not abbreviate) (Format "00-0")/
INCREMENT (Y/
From To N)
INTEGRATED PROVINCIAL HEALTH OFFICE - LANAO CONTRACT
01/09/2018 12/31/2018 NURSE II DEL SUR 31,765.00 15-1 OF SERVICE N
INTEGRATED PROVINCIAL HEALTH OFFICE - LANAO CONTRACT
01/11/2017 12/31/2017 NURSE II DEL SUR 26,878.00 N/A OF SERVICE N
INTEGRATED PROVINCIAL HEALTH OFFICE - LANAO CONTRACT
01/29/2014 12/31/2016 NURSE DEL SUR 18,549.00 N/A OF SERVICE N
INTEGRATED PROVINCIAL HEALTH OFFICE - LANAO CONTRACT
03/09/2012 02/28/2013 NURSE DEL SUR 8,000.00 N/A OF SERVICE N

(Continue on separate sheet if necessary)

SIGNATURE DATE July 29, 2019

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

(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
UNITED NATION FUND FOR POPULATION
FAMILY PLANNING COMPETENCY BASED TRAINING 07/02/2018 07/02/2018 40.0 TECHNICAL
ACTIVITIES (UNFPA)
INTERNATIONAL COMMITTEE OF THE RED
BASIC LIFE SUPPORT AND STANDARD FIRST AID TRAINING 11/28/2017 12/01/2017 32.0 TECHNICAL
CROSS (ICRC)
INTERNATIONAL COMMITTEE OF THE RED
HEALTH AND HYGEINE PROMOTION IN EMERGENCY RESPONSE TEAM 09/14/2017 09/15/2017 16.0 TECHNICAL
CROSS (ICRC)
INTEGRATED PROVINCIAL HEALTH OFFICE-
MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT TRAINING 06/23/2017 06/23/2017 8.0 TECHNICAL LANAO DEL SUR
INTEGRATED PROVINCIAL HEALTH OFFICE-
TRAINING ON SMOKING CESSATION COUNSELING 02/26/2017 02/27/2017 16.0 TECHNICAL
LANAO DEL SUR
DEPARTMENT OF HEALTH-AUTONOMOUS
TRAINING ON PHARMACEUTICAL SUPPLY CHAIN MANAGEMENT 02/15/2017 02/15/2017 8.0 TECHNICAL
REGION IN MUSLIM MINDANAO
INTEGRATED PROVINCIAL HEALTH OFFICE-
SEMINARS ON TETANUS-DIPTHERIA TOXOID SUPPLEMENTAL IMMUNIZATION 12/29/2015 12/29/2015 8.0 TECHNICAL LANAO DEL SUR

(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 full)
(Write in full)

PHILIPPINE NURSES ASSOCIATION - LANAO

READING QURAN N/A
SUR CHAPTER
PHILIPPINE LEAGUE OF GOVERNMENT AND
COMPUTER LITERATE
PRIVATE MIDWIVES
INTEGRATED MIDWIVES ASSOCIATION OF
THE PHILIPPINES

(Continue on separate sheet if necessary)

SIGNATURE DATE 07/29/2019

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 ✘ NO
YES
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? ________________________________
END OF CONTRACT
________________________________
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
NORMALLAH DIMALOTANG ALONTO, MD MARAWI CITY, LANAO DEL SUR 9999916810 3.5 cm. X 4.5 cm
(passport size)

CHONA M. LIMBARING, RN ILIGAN CITY, LANAO DEL NORTE 9363548742 With full and handwritten
name tag and signature over
printed name
NOROL-ANAH D. MACAPODI, RN, RM, MPA MARAWI CITY, LANAO DEL SUR 9185041501
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
PROFESSIONAL REGULATION COMMISSION
Government Issued ID: ID

ID/License/Passport No.: 0748849 Signature (Sign inside the box)

07/29/2019
Date/Place of Issuance: 03/14/2017 / CAGAYAN DE ORO 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