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 a
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.

I. PERSONAL INFORMATION
2. SURNAME MIRANDA

FIRST NAME LOWENDA

MIDDLE NAME GUIR

3. DATE OF BIRTH
(mm/dd/yyyy) 4/8/1980 16. CITIZENSHIP ✘ Filipino Dual Citizenship

4. PLACE OF BIRTH CANTILAN, SURIGAO DEL SUR If holder of dual citizenship,

please indicate the details.

5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS 368

Widowed Separated House/Block/Lot No.

Other/s:
Subdivision/Village
7. HEIGHT (m) 1.53 m CANTILAN
City/Municipality
8. WEIGHT (kg) 63 KGS. ZIP CODE 8317

9. BLOOD TYPE O (Rn +)

18. PERMANENT ADDRESS 368
House/Block/Lot No.

10. GSIS ID NO.

Subdivision/Village
CANTILAN
11. PAG-IBIG ID NO. 1211-4412-9235
City/Municipality

12. PHILHEALTH NO. 18-025192114.6 ZIP CODE 8317

13. SSS NO. 082-3041783 19. TELEPHONE NO.

14. TIN NO. 314-238-179-000 20. MOBILE NO. 0917-7123221

15. AGENCY EMPLOYEE NO.
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME
FIRST NAME
21. E-MAIL ADDRESS (if any) eya-alm@yahoo.com
MIRANDA 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
ALDINE TRISHA DANE G. MIRANDA

MIDDLE NAME FLORESCA ALDEAH LAINE G. MIRANDA

OCCUPATION OFW-SEAMAN ALDINE LOUIE G. MIRANDA

EMPLOYER/BUSINESS NAME CARDIFF AGENCY

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME GUIR

NAME EXTENSION (JR., SR)
FIRST NAME MANUEL

MIDDLE NAME VALEROSO

25. MOTHER'S MAIDEN NAME

SURNAME TRUGILLO

FIRST NAME CARMELITA

MIDDLE NAME LUAREZ (Continue on separate sheet if necessa

III. EDUCATIONAL BACKGROUND

26. NAME OF SCHOOL PERIOD OF ATTENDANCE

BASIC EDUCATION/DEGREE/COURSE
LEVEL (Write in
(Write in full)
full)
From To

ELEMENTARY PALASAO ELEMENTARY SCHOOL ELEMENTARY EDUCATION 1985 1991

 SURIGAO DEL SUR INSTITUTE OF
SECONDARY /
VOCATIONAL SECONDARY EDUCATION 1991 1995
TECHNOLOGY - MAIN

TRADE
UNIVERSITY OF PERPETUAL HELP BACHELOR OF SCIENCE IN
COURSE
COLLEGE 1995 1999
RIZAL - LAS PIÑAS MEDICAL TECHNOLOGY
UNIVERSITY OF PERPETUAL HELP BACHELOR OF SCIENCE IN
GRADUATE STUDIES 2005 2008
RIZAL - LAS PIÑAS NURSING
(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FO
strative/criminal case/s against the person

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Dual Citizenship
by birth by naturalization

Pls. indicate country:

RIZAL STREET
Street
MAGOSILOM
Barangay
SURIGAO DEL SUR
Province
8317
RIZAL STREET
Street
MAGOSILOM
Barangay
SURIGAO DEL SUR
Province

8317

0917-7123221

a-alm@yahoo.com

me and list all) DATE OF BIRTH (mm/dd/yyyy)

A 11/14/2001

A 10/16/2004

A 12/13/2009

on separate sheet if necessary)

HIGHEST LEVEL/ SCHOLARSHIP/

YEAR
UNITS ACADEMIC
GRADUATED
EARNED HONORS
(if not graduated) RECEIVED

SALUTATO
1991
RIAN
 SPECIAL
1995
HONOR

1998

2008

April 10, 2019

CS FORM 212 (Revised 2017), Page 1 of 4
 IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable)
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

BOARD EXAMINATION FOR NURSING 78.4 JUNE 2008 MANILA

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE
) Description of duties should be indicated in the attached Work Experience sheet.
28. INCLUSIVE DATES SALARY/ JOB/ PAY
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY
(Write in full/Do not (Write in SALARY
applicable)& STEP
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To

EMERGENCY ROOM. DEPARMENT

6/10/2015 PRESENT NURSE JOB ORDER (J.O.) ### N/A
MADRID DISTRICT HOSPITAL
EMERGENCY AND WARD DEPARTMENT
1/5/2009 7/30/2014 CLINIC NURSE 8,000.00 N/A
- ALVIZO CLINIC
LABORATORY DEPARTMENT RURAL
8/1/2008 10/31/2008 MEDICAL TECHNOLOGIST 6,000.00 N/A
HEALTH UNIT - CANTILAN
LABORATORY SECTION RURAL
2/4/2002 3/31/2003 MEDICAL TECHNOLOGIST 6,000.00 N/A
HEALTH UNIT- CANTILAN

(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 10, 201
CS FORM 212
 LICENSE (if applicable)

NUMBER Date of
Validity

0511367 2020

ue on separate sheet if necessary)

GOV'T
SERVICE

STATUS OF
APPOINTMENT

(Y/
N)
JOB ORDER YES

JOB ORDER NO

JOB ORDER YES

JOB ORDER YES

ue on separate sheet if necessary)

APRIL 10, 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 /
From To

SANGGUNIANG KABATAAN-PAG-ANTAYAN, CANTILAN ,SURIGAO DEL SUR 1/19/2018 1/19/2018 8.0 VOLUN

(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/
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To
REDCROSS
FIRST AID 3/6/2018 3/9/2018 24 TECHNICAL
BASIC LIFE SUPPORT
ADVANCE CARDIAC LIFE SUPPORT ADELA SE
9/6/2017 9/8/2017 24 TECHNICAL
PEDIATRIC ADVANCE CENTER /
CARDIAC LIFE SUPPORT
ESSENTIAL INTRAPARTUM NEWBORN CARE WORKSHOP AND BREAST ADELA SE
9/28/2017 9/28/2017 8 TECHNICAL
FEEDING ORIENTATION CENTER /
16TH
INDIVIDUAL FIRST AID KIT APPLICATION AND TACTICAL COMBAT
6/10/2016 6/10/2016 8 TECHNICAL INFANTRY
CASUALLY CARE TRAINING
ADELA SE
CUSTOMER SERVICE THE EXTRA MILE AWAY 5/19/2016 5/20/2016 16 TECHNICAL
CENTER /
HOSPITAL INTEGRATED TB DOTS TRAINING 6/6/2013 6/8/2013 24 TECHNICAL

STAKE HOLDER ADVOCACY ON HOSPITAL TB DOTS 10/5/2012 10/5/2012 8 TECHNICAL

COMMON CARDIOVASCULAR DRUGS / INFECTION CONTROL PRACTICE CRITICAL C

2/19/2009 2/19/2009 8 TECHNICAL
IN THE ICU
ASSOCIA
IV THERAPY TRAINING 1/20/2009 1/24/2009 40 TECHNICAL
ADMINIS
THE
BASIC LIFE SUPPORT / ADVANCE CARDIAC LIFE SUPPORT 12/2/2008 12/5/2018 32 TECHNICAL EMERG
PHILIP

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERS
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

DRIVING

COMPUTER LITERATE
 (Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

VOLUNTEER NURSE

eparate sheet if necessary)

ROGRAMS ATTENDED
five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

REDCROSS - TANDAG / MADRID DISTRICT

HOSPITAL

ADELA SERRA TY MEMORIAL MEDICAL

CENTER / MADRID DISTRICT HOSPITAL

ADELA SERRA TY MEMORIAL MEDICAL

CENTER / MADRID DISTRICT HOSPITAL
16TH INFANTRY BATTALION 2ND
INFANTRY DIVISION / MADRID DISTRICT
HOSPITAL
ADELA SERRA TY MEMORIAL MEDICAL
CENTER / MADRID DISTRICT HOSPITAL
DOH / CHD CARAGA

DOH / CHD CARAGA

CRITICAL CARE NURSE ASSOCIATION OF
THE PHILIPPINES\
ASSOCIATION OF NURSING SERVICES
ADMINISTRTOR OF THE PHILIPPINES
THE PHILIPPINE SOCIETY OF
EMERGENCY CARE PHYSICIANS /
PHILIPPINE GENERAL HOSPITAL

eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)
eparate sheet if necessary)

APIL 10, 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
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
SHERWIN JOSOL, MD TANDAG, SURIGAO DEL SUR 09177717850 3.5 cm. X 4.5 cm
(passport size)

ALGERICO IRIZARI, MD LANUZA, SURIGAO DEL SUR 09177036485 With full and handwritten
name tag and signature over
printed name
CATHERINE MAQUILING, RN CARRASCAL, SURIGAO DEL SUR 09304054084
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
Government Issued ID:
REGULATION COMMISSION
ID/License/Passport No.: 0511367 Signature (Sign inside the box)

Date/Place of Issuance: 9/17/2008 / MANILA 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 o
 If YES, give details (country):

, affiant exhibiting his/her validly issued government ID as indicated above.

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