WWW - Ejobs.doh - Gov.ph Ejobs Applicant PDSPrint

1/19/2015
www.ejobs.doh.gov.ph/ejobs/applicant/PDSPrint.php?operation=print
CSFORM212(Revised 2005)
PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes
1. CS ID No. (to be filled up
with "[/]" and use separate sheet if necessary.
by CSC)
I. PERSONAL INFORMATION
2. Surname: bialba
First Name: daisy mae
3.Name
Middle Name: ramirez
Extension
na
(e.g.Jr.,Sr.):
4. Date Of
Birth
1970-05-11
(mm/dd/yyyy):
16. Residential #42N. zamora
st. sfdm Address:
q.c.,
5. Place of
paltok sfdm, CITY OF MANILA,
Birt
MANILA, NCR, FIRST DISTRICT
h:
Provinc
e:
6. Sex:
FEMALE
ZipCode:
1105
17. Telephone
7. Civil Status: MARRIED
No
:
8. Citizenship: Filipino
18. Permanent 342N. zamora
9. Height (m): 0.00
10. Weight
52.27
(kg)
:
11.
Blood
B
+
12. SIS ID
No.:
G
13. Pagibig ID
No .:
any):
14.
.PhilHealth
No :
N SSS No: 03-9266362-1
15.
II. FAMINlY BACKGROUND
24. Spouse's
bialba
Surname:
First Name: roel
Surname:
Middle Name: rodriguez
Occupation: businessman
Employer
st. sfdm. Address:

ZipCode:
q.c., ,
19. Telephone Type:

No:
20.
Address
(if
i
daisybialba@yahoo.com
Ema l
any
):
21. Cellphone
1070-0040-2160
No (if
22. Agency o.:
19-051985867-7
n/a
Employee
23. TIN:
158-431-909
26. Father's
ramirez (deceased)
First Name: ruben

MiddleName: cajucom
http://www.ejobs.doh.gov.ph/ejobs/applicant/PDSPrint.php?operation=print
27.
Mother's
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1/19/2015
Name:
Busine
ss
Address:
self employed
Surname:
ramirez
342n. zamora st. sfdm q.c. First Name: emelita
Telephone No:
Middle Name: bartolome

Applicant Child
DATE OF
NAME OF CHILD(Write fullname
BIRTH
and list all)
(mm/dd/yyyy)
(Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND

Nam Degre Year
e
e of
graduated
T
o
Course Highest Units (if
28. Level
Grade
(Write
Scho in full) Earned graduated)
ol
(Writ
e
in full
)
university
08
doctor
of sto.
2012 1.0
of
DOCTORALtom
philosophy
66
as
universitymaster of
0
of sto. arts in 1998
1.0
36
7
MASTERA
0
N/A tomas
nursing
L
unite bachelor of
d
06
science in 1991
COLLEG docto
E
1.o nursing
rs
medic
al
cente
r
Place
famil Rating
ab
of 1.25 9
psychol
y 09 OTHERS
Conferm
ogy
clinic
Examination
/ ent
colleg
es
teacher
natio
09 OTHERSnal
education 2014
university
progra
m
3.5
Scholars
Fro hip /
m Academi
c Honors
Received
2004 2012 n/a
1993 1998
top 13
-1987 1991
leadership
awardee
1999 1999 N/A
6 2014 2014 N/A

IV. CIVIL SERVICE ELIGIBILITY
Career Service /
Date of
Licens
RA1080 (Board
e
Numb
Examination Bar)
er
(Under Special
/
Laws / CES / CSEE
Date
of
Releas
e
Conferment
PRC
79.80 1992-05-31 manila

0202670

2/7
199
30122
1/19/2015
V. Work Experience (Include private employment. Start

from your current work)
Salary
Position
Grade &
Gov
30.
Title
Department/Agency/Ofice/Company Monthly Step
't
To
Status of From
(Write in
(Write
(Yes/N
in full)
Salary Increment Appointment
Service
o)
full)
2010- 2013st. mary's college, quezon city
04-30 04-30 professor
regular - full
201435000.00
pamantasan ng lungsod ng maynila
time
2015- 07-01 professor
05-01
2013- 2015national university professor
35000.00
college of 05-01 07-01 education/graduate
fulltime
school
dean,
2004N/A
40000.00 regular
2010- 04-30 college of
04-30
nursi
ng
2009- 2010taguig general hospital
nursing
10-01
07-01 consultant
nurse
2005- 2011- licensure keiserworth review
20000.00
part
center/vbp review 12-31 12-31 examination
time
center
assistant
chief nurs
2000e
2004edfor cation
dr. jesus c. delgado
09-30 03-31
u
memorial hospital
25000.00
regular
quali
2001- 2003ty management DR. JESUS DELGADO MEMORIAL 0.00
12-31 12-31
HOSPITAL educati
2000- 2000on
04-30 09- and training dr. jesus c. delgado memorial hospital
16000.00
regular
30
2002trinity college
10000.00 part
2003- 09-30 lecturer
05-31
infection
20000.02 regular
2004- 03-31 control dr. jesus c. delgado memorial hospital
03-31
nur
se
2000dr. jesus c. delgado
2004- 04-01 IV trainer
04-01
Clinical
1993- 2000instructo
family clinic inc.
16000.
regular
r to
00
3/7
1/19/2015
03-01 03- assista

30 nt
profess
19921993- 03-30 staff nurse
06-01
iccumedical center
picu (iccu-picu) 5000.00
delos santos
probitionary

VI. Voluntary Work or Involvement in Civic/NonGovernment/People/Voluntary
Organizations
31. Name & Address of Inclusive
To
NumberPosition /
Organization
if
(Write in full) From
Nature of
Hours Wor
Dates
training
the2012Kanlungan ni maria home for the
2011-10k
health car
aged
01
10150.00
01
training
the2012uplift community development
2011-10providers/communi
health car
foundation
01
0260.00
15
Bahay Kanlungan ni Maria
0.16
2011-08- 2011-Domenica The
Camillian Sisters
31
Missionaries
of Charity Home
for 08-31
2011-112011- service
community
0.16
the Needy
15
1115
community
service
2011-102011Anawim Home of Gods Poor
0.16
09
10community
service
St. Lorenzo Ruiz09
Home for the
0.24
2011-05- 2011-Elderly Little Sisters
of the
Poor
31for the Elderly
06-01
St.
Joseph
Home
community
service
0.24
2011-08- 2011-Little Sister of the Poor
House of Somang Home31
for the 08-31
2011-11community
service20110.40
Elderly
04
1204Blue Whale Mission of Our Lady,
community
service
20110.16
09- 2011-Inc Home for the Elderly
30
09-30
Missionaries of Charity
Home
for
community
service
0.40
2011-10- 2011-the Sick and Aged
12-31
- Missionaries 03
of Charity Home
community
service
0.24
for 2011-10- 2011-the Sick and the
Aged service for barangay
31
10-31
community
2013-07community
service20130.32
paltok
31
0731
dental mission
community service for barangay
2013-09- 20130.24
paltok
30
0930
medical2013-07mission 2013community service for barangay
0.2
feeding program
for the paltok
31
4
07-31 children of barangay paltok
4/7
1/19/2015

paltok
201307-31

paltok
31
0731
paltok
30
0930
nurse
station
led mayor
clinic quezon
ofice
of
the vice
2011-10city anti drug abuse advisory
0.80
201131
1031
201
livelihood
0.24
program for the
3community of baran
07gay paltok
31
livelihood
2013-072013program for t 0.24
he
community
2013-062013- of barangay
4.00 freevolunteer council

VII. Training Programs (Start from the most recent training)
32. Title of
Numb Conducted/Spons
FromTo
Seminar/Conference/Worksh
ored by
er
of
op/Short Courses
(Write in full)
Hours
(Write in full)

33. Special
Skills/Hobbi
es
reading,
playing piano,
baking,
playing key
boards, playing
volleyball
VIII. Other Information

34. Non Academic
35. Member in
Distinction/Recog
Association/Organiz
nition (Write
ation (Write in full)
in full)
Philippine Nurses
Association (PNA)
Association of Deans of the
leadership awardee
Philippine Colleges
of Nursing
)ADPCN
(Continue on separate sheet

if necessary)
32. Title of
Seminar/Conference/Worksh
op/Short Courses
(Write
in full)
33. Special
34.
Non Academic
Numb
FromTo
er
of
Hours
in ful
l)
Conducted/Spons
ored by
(Write in full)
Skills/Hobbies
VIII. Other Information

35. Member in
Distinction/Recognition
Association/Organization (Write
5/7
1/19/2015
reading, playing piano,

baking, playing key boards, leadership awardee
playing volleyball
Philippine Nurses
Association (PNA)
Association of Deans of the
Philippine Colleges
of Nursing )ADPCN
36. Are you related by consaguinity or affinity to any of the following: a.

Within the third degree (for National Government
If Yes
Employees): appointing authority, recommending authority, ,
plea
chief of office/bureau/department or person who has immediate
se
specif
supervision over you in the Office, Bureau or Department where
y: you
will be appointed?
b. Within the fourth degree (for Local Government Employees): appointing
If Yes, authority or recommending authority where you will be appointed?
please
37. a. Have you ever been formally charged?
If Yes
,please specify:
b. Have you ever been guilty of any administrative offense?
If Yes
,please specify:
38. Have you ever been convicted of any crime or

violation of any law,decree, If Yes, ordinance or regulation by any court
ortribunal?
please
39. Have you ever been separated from the service in any of the following
modes: resignation, retirement, dropped from the rolls,
dismissal,termination,
If Yes, end
of term, finished contract, AWOLor phased out, in the public or private
please sector?
40. Have you ever been a candidate in a national or local election (except
If Yes, Barangay Election)?
please
41. Pursuant to: (a) Indigenous Peoples Act(RA 8371);(b)Magna Carta for
Disabled Persons(RA7277); and (c)Solo Parents Welfare Act of 2000If Yes,
(RA8972), please answer the followring items: a. Areyou a member of any
please
b. Are you differently abled?
If Yes
,please specify:
6/7
1/19/2015
If Yes,
pleas
e
speci
c. Are you a solo parent?
Name
42. References
(Person not
related by consaguinity of afinity to
applicant/appointee)
Address
Tel. No.
43. I declare under oath that this Personal Data

Sheet ha been accomplished by me,
and is a true, correct and complete pursuant to
the provisions of pertinent laws,
rules and regulations of the Republic of the Philippines.
I also authorized the agency head / authorized

representative to verify / validate the
contents stated herein. I trust that this
information shall remain confidential.
Photo:
Community Tax Certi
ficate No.
Issued At
0000-00-00
Issued
On(mm/dd/yyyy)
SIGNATURE
(Sign inside the box)
0000-00-00
Date Accomplished
CSFORM212(Revised 2005)
Back
RIGHT
THUMBMARK
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1/19/2015

PERSONAL DATA SHEET

st. sfdm. Address:

19. Telephone Type:

First Name: ruben

342n. zamora st. sfdm q.c. First Name: emelita

Middle Name: bartolome

III. EDUCATIONAL BACKGROUND

2004 2012 n/a

1999 1999 N/A

6 2014 2014 N/A

(Continue on separate sheet if necessary)

79.80 1992-05-31 manila

(Continue on separate sheet if necessary)

V. Work Experience (Include private employment. Start

03-01 03- assista

(Continue on separate sheet if necessary)

community service for barangay

community service for barangay

(Continue on separate sheet if necessary)

(Continue on separate sheet if necessary)

VIII. Other Information

(Continue on separate sheet

VIII. Other Information

reading, playing piano,

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

b. Have you ever been guilty of any administrative offense?

38. Have you ever been convicted of any crime or

c. Are you a solo parent?

43. I declare under oath that this Personal Data

I also authorized the agency head / authorized

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