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 DELA CRUZ

FIRST NAME JOSE CONRADO NAME EXTENSION (JR., SR) JR.

MIDDLE NAME RAPATAN

3. DATE OF BIRTH
04-23-1981 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH CAMILING, TARLAC If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

### CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS N/A N/A
Widowed House/Block/Lot No. Street
Separated SO. AGLAWA MULAWIN
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 157 STA CRUZ OCCIDENTAL MINDORO
City/Municipality Province
8. WEIGHT (kg) 65.5 ZIP CODE 5105

18. PERMANENT ADDRESS N/A N/A

9. BLOOD TYPE O
House/Block/Lot No. Street
SO. AGLAWA MULAWIN
10. GSIS ID NO. N/A
Subdivision/Village Barangay
STA CRUZ OCCIDENTAL MINDORO
11. PAG-IBIG ID NO. 121-255-724-527
City/Municipality Province

12. PHILHEALTH NO. 090252801595 ZIP CODE 5105

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

14. TIN NO. 317-294-736-000 20. MOBILE NO. 09435358183 / 09754067964

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) darckmann2007@yahoo.com.ph
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME VILLA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME ANGELINE RANZ AGUSTIN VILLA 06/4/2013
N/A
MIDDLE NAME TUGAS CAIA FELIZ DELA CRUZ 07/29/2018

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. 0945-079-6179

24. FATHER'S SURNAME DELA CRUZ

NAME EXTENSION (JR., SR)
FIRST NAME CONRADO
SR.
MIDDLE NAME SAGUN

25. MOTHER'S MAIDEN NAME

SURNAME RAPATAN

FIRST NAME NONITA

MIDDLE NAME BERMUNDO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY CAMILING NORTH ELEMENTARY SCHOOL PRIMARY EDUCATION 1988 1994 GRADUATED 1994 N/A

VOCATIONAL /
SECONDARY TARLAC COLLEGE OF AGRICULTURE SECONDARY EDUCATION 1994 1998 GRADUATED 1998 N/A

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

TRADE
COURSE FAR EASTERN UNIVERSITY
BACHELOR OF SCIENCE IN COMMERCE GRADUATED
1988 2002 2002
COLLEGE N/A
CENTRAL LUZON DOCTOR'S HOSPITAL- 2002 2006 2006
BACHELOR OF SCIENCE IN NURSING GRADUATED
Educational Institute

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

(Continue on separate sheet if necessary)

SIGNATURE DATE 12/21/2022

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

BOARD OF NURSING 77.60 DEC. 2006 ARELLANO UNIVERSITY MANILA 0416165 04/23/2025

(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 DEPARTMENT / AGENCY / OFFICE / SALARY/ JOB/ PAY SERVICE
POSITION TITLE GRADE (if
(mm/dd/yyyy) COMPANY STATUS OF
(Write in full/Do not MONTHLY SALARY applicable)& STEP
APPOINTMENT
(Write in full/Do not (Format "00-0")/
abbreviate)
From To abbreviate) INCREMENT
(Y/ N)
CONTRACT OF
01/2/2022 PRESENT NURSE DEPLOYMENT PROGRAM DEPARTMENT OF HEALTH 38150.00 16-0 SERVICE Y
CONTRACT OF
01/9/2019 12/31/2021 NURSE DEPLOYMENT PROGRAM DEPARTMENT OF HEALTH 32053.00 15-1 SERVICE Y
CONTRACT OF
01/7/2017 12-31-2018 PUBLIC HEALTH ASSOCIATE DEPARTMENT OF HEALTH 22145.00 N/A SERVICE Y
CONTRACT OF
07/1/2014 06-31-2017 NURSE DEPLOYMENT PROGRAM DEPARTMENT OF HEALTH 26876.00 N/A SERVICE Y
CONTRACT OF
01/3/2012 12-20-2013 PHARMACY STORE SUPERVISOR LAMPA FARMACY 8000.00 N/A SERVICE N
CONTRACT OF
12/2/2011 02-15-2012 RN-HEALS DEPARTMENT OF HEALTH 8000.00 N/A SERVICE Y

(Continue on separate sheet if necessary)

SIGNATURE DATE 12/21/2022

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

TRAINING OF TRAINERS FOR CONTRACT TRACING TEAM (CCT) IN MIMAROPA 09/23/20 09/23/20 8.0 TECHNICAL DEPARTMENT OF HEALTH

TRANSFORMING INFECTION PREVENTION & CONTROL PRACTICES UTILIZING BUNDLES

11/11/2018 11/11/2018 8.0 TECHNICAL INSTITUTE FOR CONTINUING ADVANCEMENT INC.
OF CARE: A SEMINAR-WORKSHOP

INTERNATIONAL PATIENT SAFETY GOALS 01/10/2018 01/10/2018 8.0 TECHNICAL HEALTHCARE ADVANTAGE TRAINING INSTITUTE

ON BASIC ELECTROCARDIOGRAPHY READING TRAINING 09-21-2018 09-21-2018 8.0 TECHNICAL HEALTHCARE ADVANTAGE TRAINING INSTITUTE

USERS TRAINING ON MOBILE APPLICATION OF HEALTH FACILITY PROFILE AND

09-26-2018 09-27-2018 16.0 TECHNICAL DEPARTMENT OF HEALTH
NATIONAL HEALTH FACILITY REGISTRY
CONTINUING PROFESSIONAL DEVELOPMENT: "FRAMEWORK FOR QUALITY ASSURANCE
11/30/2018 11/30/2018 8.0 TECHNICAL PHILIPPINE NURSES ASSOCIATION, INC. (PNA)
PROGRAM FOR FILIPINO NURSES"
TRAINING ON THE HEALTH SECTOR PERFORMANCE MONITORING AND EVALUATION
07-25-2017 07-28-2017 32.0 TECHNICAL DEPARTMENT OF HEALTH
SYSTEM
ASSOCIATION OF NURSING SERVICES
REGULAR IV TRAINING PROGRAM 05/23/2012 05/25/2012 24.0 TECHNICAL
ADMINISTRATOR OF THE PHILIPPINES (ANSAP)
PROVINCIAL HEALTH OFFICE, OCCIDENTAL
FAMILY PLANNING COMPETENCY BASED TRANING COURSE 05/16/2011 05/21/2011 48.0 TECHNICAL
MINDORO

(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)

COMPUTER LITERATE N/A PHILLIPINE NURSES ASSOCIATION

(Continue on separate sheet if necessary)

SIGNATURE DATE 12/21/2022

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
DR. ROBERTO LIABRES STA. CRUZ 09177922393 3.5 cm. X 4.5 cm
(passport size)

DR. WILFRED G. KENEPT SABLAYAN 09153945812 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

ID/License/Passport No.: 0416165

Signature (Sign inside the box)
12/21/2022
Date/Place of Issuance: 02/13/2007, 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 of 4