CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes with " " and use separate sheet if necessary. 1. CS ID No. (to be filled up by CSC)

I. PERSONAL INFORMATION
2. SURNAME CHUA

FIRST NAME JOHN CARLO

MIDDLE NAME GUARDACASA

4. DATE OF BIRTH (mm/dd/yyyy) 10/09/1986 16. RESIDENTIAL ADDRESS
PUROK BAGONG SIKAT, NEW AGUTAYA, SAN VICENTE,
5. PLACE OF BIRTH
PALAWAN
6. SEX Male Female
7. CIVIL STATUS Single Widowed ZIP CODE 5309
Married Separated
17. TELEPHONE NO. N/A
Others, specify ___________
18. PERMANENT ADDRESS
PUROK BAGONG SIKAT, NEW AGUTAYA, SAN VICENTE,
8. CITIZENSHIP FILIPINO
PALAWAN
9. HEIGHT (m) 1.7
10. WEIGHT (kg) 70 ZIP CODE 5309
11. BLOOD TYPE "O" 19. TELEPHONE NO. N/A
12. GSIS ID NO. 006-0175-6430-0 20. E-MAIL ADDRESS (if any) jcgchua@yahoo.com.ph
13. PAG-IBIG ID NO. 913037131172 21. CELLPHONE NO. (if any) (63)9473379102
14. PHILHEALTH NO. 09-000080426-5 22. AGENCY EMPLOYEE NO.MHO-023
15. SSS NO. 0422143749 23. TIN 408-457803
II. FAMILY BACKGROUND
24. SPOUSE'S SURNAME CHUA 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
FIRST NAME RUTH JOY CHUA, CHESAH SALENN V. 11/25/2020
MIDDLE NAM VARQUEZ N/A N/A
OCCUPATION QUALITY ASSURANCE NURSE N/A N/A
EMPLOYER/BUS. NAMCAERUS STRATEGIC N/A N/A
BUSINESS ADDRESS N/A N/A
TELEPHONE NO. N/A N/A N/A
(Continue on separate sheet if necessary)
26. FATHER'S SURNAME CHUA N/A N/A
FIRST NAME LEONARDO N/A N/A
MIDDLE NAME CRUZ N/A N/A
27. MOTHER'S MAIDEN NAME
SURNAME GUARDACASA N/A N/A
FIRST NAME HELEN N/A N/A
YEAR
MIDDLE NAME CALIPUS GRADUAT (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND ED
HIGHEST
INCLUSIVE DATES OF SCHOLARSHIP/
28. NAME OF SCHOOL DEGREE COURSE GRADE/ LEVEL/
ATTENDANCE ACADEMIC
LEVEL (Write in UNITS
HONORS
(Write in full) full) EARNED From To RECEIVED
(if not graduated)
ELEMENTARY SAN VICENTE CENTRAL SCHOOL PRIMARY 2000 GRADUATE 1994 2000 3RD HONOR
(if
graduated)
VOCATIONAL
SECONDARY / SAN VICENTE NATIONAL HIGH SCHOOL SECONDARY 2004 GRADUATE 2000 2004 6TH HONOR

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

COLLEGE
TRADE COURSE OUR LADY OF FATIMA UNIVERSITY TERTIARY 2008 GRADUATE 2004 2008 N/A

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

EMERGENCY
GRADUATE STUDIES LIFE SUPPORT TRAINING MEDICAL
2019 GRADUATE 2019 2019 N/A
INTERNATIONAL TECHNICIAN
BASIC

(Continue on separate sheet if necessary)

IV. CIVIL SERVICE ELIGIBILITY
DATE OF
29. LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ EXAMINATIO
BAR) UNDER SPECIAL LAWS/ CES/ RATING N/ PLACE OF EXAMINATION / CONFERMENT
NUMBER DATE OF
CSEE CONFERMEN
RELEASE
T
BOARD OF NURSING 76.40% 06/25/2020 ADAMSON UNIVERSITY MANILA 049677 9/10/2019

EMERGENCY MEDICAL TECHNICIAN BASIC N/A N/A LIFE SUPPORT TRAINING INTERNATIONAL B-03963 5/14/2019

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

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

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

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

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

GOV'T
(Continue on separate sheet if necessary) SERVICE
V. WORK EXPERIENCE (Include private employment. Start from your current work) SALARY
GRADE &
30. INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / STEP STATUS OF
(mm/dd/yyyy) MONTHLY
COMPANY INCREME APPOINTM
(Write in full) SALARY
From To (Write in full) NT ENT
(Format
11/26/2010 PRESENT NURSE 1 MUNICIPAL HEALTH OFFICE P28,000 "00-0") PERMANEN
SG11-3 YES
T (Yes /
CONTRACR No)
01/07/2009 09/30/2009 CONTRACTUAL NURSE ROXAS MEDICARE 8,000 YES
UAL
CONTRACR
01/04/2009 06/30/2009 CONTRACTUAL NURSE RURAL HEALTH UNIT-SAN VICENTE 8,000 YES
UAL

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

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

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 (Continue on separate sheet if necessary)
CS FORM 212 (Revised 2005), Page 2 of 4
V. WORK EXPERIENCE (Include private employment. Start from your current work) GRADE &
30. INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / STEP STATUS OF
MONTHLY
(mm/dd/yyyy) COMPANY INCREME APPOINTM
SALARY
From To (Write in full) (Write in full) NT ENT
(Format
N/A N/A N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A N/A N/A
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N/A N/A N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)
CS FORM 212 (Revised 2005), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
31. NAME & ADDRESS OF ORGANIZATION NUMBER OF
(Write in full) (mm/dd/yyyy) POSITION / NATURE OF WORK
HOURS
From To

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

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

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

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

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

(Continue on separate sheet if necessary)

VII. TRAINING PROGRAMS (Start from the most recent training.)

INCLUSIVE DATES OF ATTENDANCE
32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT NUMBER OF CONDUCTED/ SPONSORED BY
COURSES (Write in full) (mm/dd/yyyy) HOURS (Write in full)
From To
LIFE SUPPORT TRAINING
EMERGENCY MEDICAL TECHNICIAN BASIC 03/15/2019 05/25/2019 480 INTERNATIONAL

PRE-HOSPITAL EMERGENCY TRUAMA CARE 04/16/2019 05/15/2019 40

LIFE SUPPORT TRAINING
INTERNATIONAL
LIFE SUPPORT TRAINING
PROVIDER OF BASIC LIFE SUPPORT 04/20/2019 05/05/2019 40
INTERNATIONAL

AMBULANCE OPERATION 09/09/2018 09/13/2018 40 PHILIPPINE RED CROSS

PHILIPPINE MENTAL HEALTH

MENTAL HEALTH COMMUNITY-BASED PROGRAM 06/28/2018 06/31/2018 32
ASSOCIATION

FIRST AID OLYMPIC 12/16/2017 12/16/2017 8 MDRRMO-SAN VICENTE

BUREAU OF FIRE
11/05/2017 08/11/2017 24
FIREFIGHTER TRAINING PROTECTION
TRAINING OF TRAINERS ON CULTURE,GENDER AND CONTEXT OF PHILIPPINE NGO COUNCIL ON POPULATION
09/03/2018 03/09/2018 18
SEXUAL AND REPRODUCTIVE HEALTH HEALTH AND WELFARE

REFERRAL NETWORK MEETING 07/31/2018 07/31/2018 8 ONP

HIV/AIDS ORIENTATION FOR THE LOCAL CHIEF EXECUTIVES OF

PALAWAN
04/17/2018 04/17/2018 8 PILIPINAS SHELL FOUNDATION

NATIONAL STRATEGIC PLAN FOR THE CONTROL AND ELIMINATION

OF MALARIA IN THE PHILIPPINES
03/26/2018 03/28/2018 16 PILIPINAS SHELL FOUNDATION

PHILIPPINE MARINE CORPS 4TH

WSAR TRAINING 12/21/2018 12/21/2018 8
MARINE BATTALION
PROVINCIAL GOVERNMENT OF
COMMUNITY BASED DRUG RECOVERY PROGRAM 10/07/2018 10/07/2018 8
PALAWAN

INTRAVENOUS THERAPHY TRAINING 07/01/2009 07/03/2009 24 PAH-ACCREDITED BY ANSAP

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION: ASSOCIATION/ORGANIZATION
33. SPECIAL SKILLS / HOBBIES: 34. 35.
(Write in full)
(Write in full)

HANDLE NORMAL SPONTANEOUS DELIVERY N/A N/A

PERINEAL REPAIR N/A N/A

DRIVING N/A N/A

COMPUTER LITERATE N/A N/A

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2005), Page 3 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
NAME & ADDRESS OF ORGANIZATION
31.
(Write in full) NUMBER OF
(mm/dd/yyyy) POSITION / NATURE OF WORK
HOURS
From To

(Continue on separate sheet if necessary)

VII. TRAINING PROGRAMS (Start from the most recent training.)

INCLUSIVE DATES OF ATTENDANCE
32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT NUMBER OF CONDUCTED/ SPONSORED BY
COURSES (Write in full) (mm/dd/yyyy) HOURS (Write in full)
From To

(Continue on separate sheet if necessary)

 CS FORM 212 (Revised 2005), Page 3 of 4

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

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

(Continue on separate sheet if necessary)

VII. TRAINING PROGRAMS (Start from the most recent training.)
INCLUSIVE DATES OF ATTENDANCE
32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT NUMBER OF CONDUCTED/ SPONSORED BY
COURSES (Write in full) (mm/dd/yyyy) HOURS (Write in full)
From To

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2005), Page 3 of 4
36. Are you related by consanguinity or affinity to any of the following :

a. Within the third degree (for National Government Employees): YES NO

appointing authority, recommending authority, chief of office/bureau/department or person who If YES, give details:
has immediate supervision over you in the Office, Bureau or Department where you will be _____________________________________
appointed? _____________________________________
_____________________________________

b. Within the fourth degree (for Local Government Employees): YES NO

appointing authority or recommending authority where you will be appointed? If YES, give details:
_____________________________________
_____________________________________
_____________________________________
37 a. Have you ever been formally charged? YES NO
If YES, give details:
________________________________
________________________________
b. Have you ever been guilty of any administrative offense? YES NO
If YES, give details:
________________________________
________________________________
38. Have you ever been convicted of any crime or violation of any law, decree, ordinance or YES NO
regulation by any court or tribunal? If YES, give details:
________________________________
________________________________
39. 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, AWOL
or phased out, in the public or private sector? If YES, give details:

40. Have you ever been a candidate in a national or local election (except Barangay election)? YES NO
If YES, give details:
________________________________
________________________________
41. 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 differently abled? YES NO
If YES, please specify: ____________________
c. Are you a solo parent? YES NO
If YES, please specify: ____________________
42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)

NAME ADDRESS TEL. NO.

BONIFACIO ESTORNINOS JR.,MD POBLACION, SVP 9209758872 ID picture taken within

the last 6 months
MERCY GRACE SIPOLE-PABLICO,MD POBLACION, SVP 9985671156 3.5 cm. X 4.5 cm
(passport size)
JENELYN LARO NEW AGUTAYA,SVP 9985694947
Computer generated
43. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and or xerox copy of picture
is not acceptable
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the
Philippines.

I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust
that this information shall remain confidential. PHOTO

08550093
COMMUNITY TAX CERTIFICATE NO.
ISSUED AT
SAN VICENTE,PALAWAN SIGNATURE (Sign inside the box)
ISSUED ON (mm/dd/yyyy) 07/14/2020
01/15/2020 DATE ACCOMPLISHED RIGHT THUMBMARK
 CS FORM 212 (Revised 2005), Page 4 of 4

36.

a. Within the third degree (for National Government Employees): YES NO

appointing authority, recommending authority, chief of office/bureau/department or person who If YES, give details:
has immediate supervision over you in the Office, Bureau or Department where you will be _____________________________________
appointed? _____________________________________
b. Within the fourth degree (for Local Government Employees): _____________________________________
YES NO
appointing authority or recommending authority where you will be appointed? If YES, give details:
_____________________________________
_____________________________________
37 a. Have you ever been formally charged? _____________________________________
YES NO
If YES, give details:
b. Have you ever been guilty of any administrative offense? YES NO
________________________________
________________________________
If YES, give details:
________________________________
________________________________
38. Have you ever been convicted of any crime or violation of any law, decree, ordinance or YES NO
regulation by any court or tribunal? If YES, give details:
________________________________
________________________________
39. 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, AWOL
or phased out, in the public or private sector? If YES, give details:

40. Have you ever been a candidate in a national or local election (except Barangay election)? YES NO
If YES, give details:
________________________________
________________________________
41. 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 differently abled? YES NO
If YES, please specify: ____________________
c. Are you a solo parent? YES NO
If YES, please specify: ____________________

42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)

NAME ADDRESS TEL. NO.

MRS. ROSE PALAS POLYTECHNIC UNIVERSITY OF THE PHILIPPINES

ID picture taken within
DR. ENRICO TUY TONDO MEDICAL CENTER
the last 6 months
DR. NOEL CORONEL TONDO MEDICAL CENTER 3.5 cm. X 4.5 cm
(passport size)
43. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and

Computer generated
I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust or xeroxPHOTO
copy of picture
is not acceptable
that this information shall remain confidential.

COMMUNITY TAX CERTIFICATE NO.

ISSUED AT SIGNATURE (Sign inside the box)

ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

CS FORM 212 (Revised 2005), Page 4 of 4

CS FORM 212 (Revised 2005), Page 4 of 4

36. Are you related by consanguinity or affinity to any of the following :

a. Within the third degree (for National Government Employees): YES NO

appointing authority, recommending authority, chief of office/bureau/department or person who If YES, give details:
has immediate supervision over you in the Office, Bureau or Department where you will be _____________________________________
appointed? _____________________________________
b. Within the fourth degree (for Local Government Employees): _____________________________________
YES NO
appointing authority or recommending authority where you will be appointed? If YES, give details:
_____________________________________
_____________________________________
37 a. Have you ever been formally charged? _____________________________________
YES NO
If YES, give details:
b. Have you ever been guilty of any administrative offense? YES NO
If YES, give details:
________________________________
________________________________
38. Have you ever been convicted of any crime or violation of any law, decree, ordinance or YES NO
regulation by any court or tribunal? If YES, give details:
________________________________
________________________________
39. 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, AWOL
or phased out, in the public or private sector? If YES, give details:

40. Have you ever been a candidate in a national or local election (except Barangay election)? YES NO
If YES, give details:
________________________________
________________________________
41. 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 differently abled? YES NO
If YES, please specify: ____________________
c. Are you a solo parent? YES NO
If YES, please specify: ____________________

42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)

NAME ADDRESS TEL. NO.

ID picture taken within

the last 6 months
3.5 cm. X 4.5 cm
43. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and (passport size)

Computer generated
I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust PHOTO
or xerox copy of picture
that this information shall remain confidential. is not acceptable

08550093
COMMUNITY TAX CERTIFICATE NO.

San Vicente, Palawan

ISSUED AT SIGNATURE (Sign inside the box)

02/07/2014
ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

CS FORM 212 (Revised 2005), Page 4 of 4