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 GONZALES
NAME EXTENSION (JR., SR) JR
FIRST NAME ROGELIO

MIDDLE NAME NACION

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 04/24/1973 ✘ Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH QUEZON CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS BLOCK 12 LOT 14 GOOD SHEPHERD
House/Block/Lot No. Street
Separat
Widowed TAGAYTAY EXECUTIVE VILLAGE SAN JOSE
Other/s: ed
Subdivision/Village Barangay

7. HEIGHT (m) 1.65 TAGAYTAY CITY CAVITE

City/Municipality Province
8. WEIGHT (kg) 90 ZIP CODE 4120

9. BLOOD TYPE O- 18. PERMANENT ADDRESS BLOCK 12 LOT 14 GOOD SHEPHERD

House/Block/Lot No. Street
TAGAYTAY EXECUTIVE VILLAGE SAN JOSE
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121227574829 TAGAYTAY CITY CAVITE

City/Municipality Province

12. PHILHEALTH NO. 007030003776 ZIP CODE 4120

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

14. TIN NO. 4763855090000 20. MOBILE NO. 0927-2219014

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME GONZALES 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME QUENNIE JOY N/A GABRIELGONZALES 10/20/2011

MIDDLE NAME NISAY FRANCESCA GONZALES 1/2/2016

OCCUPATION HOUSEWIFE xxx xxx

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME GONZALES

NAME EXTENSION (JR., SR)
FIRST NAME ROGELIO N/A

MIDDLE NAME CRUZ

25. MOTHER'S MAIDEN NAME

SURNAME NACION

FIRST NAME JUANA

MIDDLE NAME AGUAS (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY UNIVERSITY OF ASSUMPTION ELEMENTARY 1980 1986 GRADUATED 1986 N/A

SECONDARY
VOCATIONAL / JOSE ABAD SANTOS HIGH SCHOOL HIGH SCHOOL 1986 1990 GRADUATED 1990 N/A

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

TRADE
COURSE
COLLEGE UNIVERSITY OF SANTO TOMAS BACHELOR OF SCIENCE IN 1990 1994 GRADUATED 1994 N/A
CHEMISTRY

GRADUATE STUDIES ANGELES UNIVERSITY FOUNDATION DOCTOR OF MEDICINE 1995 1999 GRADUATED 1999 N/A
(Continue on separate sheet if necessary)

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

PHYSICIAN LICENSURE 78.92 08/31/2000 MANILA 0093961 04/24/2025

xxx xxx xxx xxx xxx xxx

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

03/01/2020 12/30/2022 TELECONSULT DOCTOR SELF EMPLOYED 80,000.00 N/A N/A N

06/25/2018 01/21/2019 MEDICAL OFFICER III DEPARTMENT OF EDUCATION - BALANGA CITY 60,000.00 21 PERMANENT Y

05/01/2004 06/01/2018 PRIVATE CONSULT DOCTOR SELF EMPLOYED 60,000.00 N/A N/A N

10/01/2000 03/26/2004 EMERGENCY ROOM PHYSICIAN MAKABALI MEMORIAL HOSPITAL 30,000.00 N/A N/A N

xxx xxx xxx xxx xxx xxx xxx xxx

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

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
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE Type of LD
( 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
31. SPECIAL SKILLS and HOBBIES 32. NON-ACADEMIC DISTINCTIONS / RECOGNITION (Write in full) 33. (Write in
full)

DRAWING N/A N/A

xxx

(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? YES ✘ NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘ NO
If YES, give details:
________________________________
N/A

35. a. Have you ever been found guilty of any administrative offense?
YES ✘ NO
If YES, give details:
________________________________
N/A
________________________________

b. Have you been criminally charged before any court? YES ✘ NO

If YES, give details:
________________________________
Date Filed: N/A
________________________________
Status of Case/s: N/A
36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation
by any court or tribunal? YES ✘ NO
If YES, give details:
________________________________
N/A
________________________________
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 ✘ YES NO
out (abolition) in the public or private sector? If YES, give details:
________________________________
RESIGNED FROM DEPARTMENT OF EDUCATION BALANGA
________________________________
CITY

38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? YES ✘ NO
If YES, give details: N/A
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: N/A
39. Have you acquired the status of an immigrant or permanent resident of another country?
YES ✘ NO
If YES, give details (country):
N/A
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: N/A
b. Are you a person with disability? YES ✘ NO
If YES, please specify ID No: N/A
c. Are you a solo parent? YES ✘ NO
If YES, please specify ID No: N/A

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

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
ARTHUR DELA RESMA MEXICO PAMPANGA 09959647443 3.5 cm. X 4.5 cm
(passport size)
BRANDO ANGELES SAN FERNANDO PAMPANGA 09473884331 With full and handwritten
name tag and signature over
printed name
JEFFREY BOGNOT SAN FERNANDO PAMPANGA 09175425888
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
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable
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
administrative/criminal case/s against me. PHOTO

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

ID/License/Passport No.: 0093961 Signature (Sign inside the box)

Date/Place of Issuance: 08/31/2000 / MANILA Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.

HON. JENNIFER AUSTRIA-BARZAGA

CITY MAYOR
Person Administering Oath
CS FORM 212 (Revised 2017), Page 4 of 4