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 MODILLAS
NAME EXTENSION (JR., SR)
FIRST NAME CAMILLE-ANN

MIDDLE NAME DUCUSIN

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 08/24/1998

4. PLACE OF BIRTH RIYADH, KINGDOM OF SAUDI ARABIA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX

17. RESIDENTIAL ADDRESS 426 PLUTO STREET

6 CIVIL STATUS
House/Block/Lot No. Street

Subdivision/Village Barangay
1012 TONDO, MANILA
7. HEIGHT (m) 1.65 m
City/Municipality Province
8. WEIGHT (kg) 60 kg ZIP CODE

18. PERMANENT ADDRESS BLOCK 28 LOT 25 ANDREW STREET

9. BLOOD TYPE O+
House/Block/Lot No. Street
METROGATE SUBDIVISION
10. GSIS ID NO. N/A
Subdivision/Village Barangay
4026 STA. ROSA LAGUNA
11. PAG-IBIG ID NO. N/A
City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE

13. SSS NO. N/A 19. TELEPHONE NO. 2304020

14. TIN NO. N/A 20. MOBILE NO. 09162568867

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) camillemodillas@rocketmail.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

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME MODILLAS

NAME EXTENSION (JR., SR)
FIRST NAME CARMELO

MIDDLE NAME ESTRELLAS

25. MOTHER'S MAIDEN NAME AMY NATAN DUCUSIN

SURNAME MODILLAS

FIRST NAME AMY

MIDDLE NAME DUCUSIN (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

5TH HONORABLE
ELEMENTARY PALM CREST INTERNATIONAL SCHOOL ELEMENTARY 2008 2011 N/A 2011 MENTION
MERITT &
KALIPUNAN NG
SECONDARY
VOCATIONAL / NEW ERA UNIVERSITY HIGH SCHOOL 2011 2015 N/A 2015 HUWARANG
KABATAAN (KHK)
AWARDEE

N/A N/A N/A N/A N/A N/A N/A

TRADE
COURSE
COLLEGE PAMANTASAN NG LUNGSOD NG MAYNILA BACHELOR OF SCIENCE IN NURSING 2015 2019 N/A 2019 N/A

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A

(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) 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

DRIVER'S LICENCSE N/A N/A LTO BIÑAN LAGUNA D04-19-009389 24-Aug-23

PHILIPPINE COLLEGE OF CRIMINOLOGY / PRC

PRC ID 83.80 3/5/2020 9276569 24-Aug-23
STA. ROSA LAGUNA

(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)

04/02/2020 Present DOH Volunteer Nurse (Covid19) Philippine General Hospital N/A N/A Volunteer Yes

(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
29. NAME & ADDRESS OF ORGANIZATION
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

TAGUIG COMMUNITY 06/27/2018 06/27/2018 8.0 MEASLES OUTBREAK MASS VACCINATION - VACCINATOR

SABAYANG PATAK KONTRA POLIO - ROUND 2 27/11/2019 07/12/2019 8.0 MASS VACCINATION - VACCINATOR

(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

N/A N/A N/A N/A N/A N/A

(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)

Sufficient knowledge to provide competent care Treasurer, Rotaract Club of Tugon-Rescue Rotaract Club of tugon-Rescue

Computer literate Treasurer, PLM College of Nursing Student Council

Good communication Skills Junior Officer, PLM College of Nursing Student Council

Collaborative

Watch movies & series

Reading books

(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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
________________________________

35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court?
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
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,
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
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last
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?
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?
If YES, please specify:
b. Are you a person with disability?
If YES, please specify ID No:
c. Are you a solo parent?
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. Mary Pauline V. Saquing 9273951141 3.5 cm. X 4.5 cm
(passport size)

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: PRC License

ID/License/Passport No.: 0927569

Signature (Sign inside the box)

Date/Place of Issuance: 03/05/2020 PRC-Sta. Rosa Laguna

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