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 N (Do not fill up. For CSC use only)

I. PERSONAL INFORMATION
2. SURNAME BORROMEO
FIRST NAME SENECA JILL NAME EXTENSION (JR., SR) N/A
MIDDLE NAME CACAY
3. DATE OF BIRTH
(mm/dd/yyyy) 03/25/1994 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH MALAYBALAY CITY, BUKIDNON If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS MAMBALUNGKAS ST.

Widowed Separated House/Block/Lot No. Street

Other/s:
KALASUNGAY
Subdivision/Village Barangay
7. HEIGHT (m) 1.52m MALAYBALAY CITY BUKIDNON
City/Municipality Province
8. WEIGHT (kg) 57kg. ZIP CODE 8700
9. BLOOD TYPE "O" RH negative
18. PERMANENT ADDRESS MAMBALUNGKAS ST.
House/Block/Lot No. Street
10. GSIS ID NO. N/A KALASUNGAY
Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A MALAYBALAY CITY BUKIDNON

City/Municipality Province
12. PHILHEALTH NO. 15-050422571-4 ZIP CODE 8700
13. SSS NO. N/A 19. TELEPHONE NO. N/A
14. TIN NO. 499 421 158 000 20. MOBILE NO. 0995-161-9886
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) borromeosenecajill@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME TADO 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

NAME EXTENSION (JR., SR) N/A

FIRST NAME FRANCIS CHRISTIAN TADO, SENECA DENISE B. 07/31/2022
MIDDLE NAME CASINABE
OCCUPATION BUSINESSMAN
EMPLOYER/BUSINESS NAME SENTIAN TRUCKING SERVICES
BUSINESS ADDRESS MALAYBALAY CITY, BUKIDNON
TELEPHONE NO. N/A
24. FATHER'S SURNAME BORROMEO
NAME EXTENSION (JR., SR) N/A
FIRST NAME ELDIE
MIDDLE NAME ROJAS
25. MOTHER'S MAIDEN NAME

SURNAME CACAY
FIRST NAME ELENITA
MIDDLE NAME LINOAY (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

WITH
ELEMENTARY KALASUNGAY ELEMENTARY SCHOOL ELEMENTARY 1998 2006 GRADUATED 2006
HONOR
WITH
SECONDARY /
VOCATIONAL BUKIDNON NATIONAL HIGH SCHOOL HIGH SCHOOL 2006 2010 GRADUATED 2010
HONOR

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

TRADE
LICEO DE CAGAYAN UNIVERSITY, BACHELOR OF SCIENCE IN
COURSE
COLLEGE 2010 2015 GRADUATED 2015 N/A
BUIDNON STATE UNIVERSITY NURSING

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

(Continue on separate sheet if necessary)
SIGNATURE DATE AUGUST 24, 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
NOVEMBER 29-30,
NURSES LICENSURE EXAMINATION 81.80% CAGAYAN DE ORO CITY 0874070 03/25/2025
2015

(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)
(Write in full/Do not (Write in MONTHLY SALARY applicable)& STEP STATUS OF APPOINTMENT
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To (Y/ N)

DEPARTMENT OF HEALTH CENTER FOR

COMMUNITY HEALTH NURSE, NURSE II- CONTRACT OF
01/13/2021 12/31/2021 HEALTH DEVELOPMENT-NORTHERN 32,053.00 15-0 Y
(NURSE DEPLOYMENT POJECT) SERVICE
MINDANAO

DEPARTMENT OF HEALTH CENTER FOR

COMMUNITY HEALTH NURSE, NURSE II- CONTRACT OF
01/22/2020 12/31/20 HEALTH DEVELOPMENT-NORTHERN 32,053.00 15-0 Y
(NURSE DEPLOYMENT POJECT) SERVICE
MINDANAO

DEPARTMENT OF HEALTH CENTER FOR

COMMUNITY HEALTH NURSE, NURSE II- CONTRACT OF
10/02/2019 12/31/2019 HEALTH DEVELOPMENT-NORTHERN 30,531.00 15-0 Y
(NURSE DEPLOYMENT POJECT) SERVICE
MINDANAO

DEPARTMENT OF HEALTH CENTER FOR

COMMUNITY HEALTH NURSE, NURSE II- CONTRACT OF
11/01/2018 12/31/2018 HEALTH DEVELOPMENT-NORTHERN 30,531.00 15-0 Y
(NURSE DEPLOYMENT POJECT) SERVICE
MINDANAO

DEPARTMENT OF HEALTH CENTER FOR

COMMUNITY HEALTH NURSE (NURSE CONTRACT OF
02/16/2017 12/31/2017 HEALTH DEVELOPMENT-NORTHERN 31, 765.00 15-0 Y
DEPLOYMENT POJECT) SERVICE
MINDANAO

(Continue on separate sheet if necessary)

SIGNATURE DATE AUGUST 24, 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

MENTAL HEALTH PROGRAM ORIENTATION 06/03/2020 06/03/2020 8 HOURS TECHNICAL MALAYBALAY CITY HEALTH OFFICE

COMMUNITY BASED MONITORING INFORMATION SYSTEM ORIENTATION 05/03/2020 05/03/2020 8 HOURS TECHNICAL MALAYBALAY CITY HEALTH OFFICE

NUTRITION MONITORING AND EVALUATION PROTOCOL 08/16/2019 08/16/2019 8 HOURS TECHNICAL SUMILAO NUTRITION OFFICE

#BTS (BEHIND THE SOCIAL MEDIA) DO'S AND DON'TS OF PERIOPERATIVE NURSES IN OPERATING ROOM NURSES ASSOCIATION-
01/20/2019 01/20/2019 8 HOURS TECHNICAL
THE AGE OF SOCIAL MEDIA BUKIDNON CHAPTER

LICEO DE CAGAYAN UNIVERSITY- NURSING

THE ETHICS OF HIV/AIDS CARE 04/15/2018 04/15/2018 8 HOURS TECHNICAL
GRADUATE SCHOOL

(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)

CAN UNDERSTAND AND CAN SPEAK BINUKID

(BUKIDNON) LANGUAGE

DRIVING

READING BOOKS

MICROSOFT OFFICE WORKING KNOWLEDGE (MS

WORD, EXCEL, POWER POINT)

NET SURFING

(Continue on separate sheet if necessary)

SIGNATURE DATE AUGUST 24, 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? ________________________________
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
ADRIAN JED GARRETTE J. LUCERO, MD EL SALVADOR, MIS. OR 9177166724 3.5 cm. X 4.5 cm
(passport size)

DENNIS P. SANGALANG, MD MALAYBALAY CITY, BUK 9177194588 With full and handwritten
name tag and signature over
printed name
CARREN EMIROSE SOLIDOR, MD VALENCIA CITY, BUK 9171349883
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: PHILIPPINE REGULATORY COMMISSION

ID/License/Passport No.: 0874070 Signature (Sign inside the box)

AUGUST 24, 2022
Date/Place of Issuance: 1/17/2019/CAGAYAN DE ORO CITY
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