CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

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

I. PERSONAL INFORMATION
2. SURNAME GUMIRAN

FIRST NAME SHAY ANN

MIDDLE NAME JUAN 3. NAME EXTENSION (e.g. Jr., Sr.)

4. DATE OF BIRTH (mm/dd/yyyy) 07/01/1987 16. RESIDENTIAL ADDRESS

5. PLACE OF BIRTH TUGUEGARAO, CAGAYAN 131-B ARELLANO EXT., UGAC SUR TUGUEGARAO CITY
6. SEX Male Female
7. CIVIL STATUS Single  Widowed ZIP CODE 3500
Married  Separated 17. TELEPHONE NO. 304-0584
 Annulled Others, specify ___________ 18. PERMANENT ADDRESS

8. CITIZENSHIP FILIPINO 131-B ARELLANO EXT., UGAC SUR TUGUEGARAO CITY

9. HEIGHT (m) 1.56
10. WEIGHT (kg) 42kgs. ZIP CODE 3500
11. BLOOD TYPE "O" 19. TELEPHONE NO. 304-0584
12. GSIS ID NO. NONE 20. E-MAIL ADDRESS (if any) [email protected]

13. PAG-IBIG ID NO. NONE 21. CELLPHONE NO. (if any) 09272301245

14. PHILHEALTH NO. NONE 22. AGENCY EMPLOYEE NO. NONE

15. SSS NO. NONE 23. TIN NONE

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME NONE 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME NONE

MIDDLE NAME NONE
OCCUPATION NA / /
EMPLOYER/BUS. NAME NA / /
BUSINESS ADDRESS NA / /
TELEPHONE NO. NONE / /
(Continue on separate sheet if necessary) / /
26. FATHER'S SURNAME GUMIRAN
FIRST NAME DEMETRIO / /
MIDDLE NAME DARISAN / /
27. MOTHER'S MAIDEN NAME / /
SURNAME JUAN
FIRST NAME ANITA / /
MIDDLE NAME CUZZAMU (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND YEAR

GRADUATED
INCLUSIVE DATES OF
28. HIGHEST GRADE/
NAME OF SCHOOL DEGREE COURSE ATTENDANCE SCHOLARSHIP/
LEVEL/
LEVEL (Write in (Write in full) ACADEMIC HONORS
UNITS EARNED
full) From To RECEIVED
(if not graduated)

TUGUEGARAO WEST CENTRAL ELEMENTARY (if graduated)

ELEMENTARY SCHOOL 2000 1994 2000

UNIVERSITY OF SAINT LOUIS TUGUEGARAO

SECONDARY 2004 2000 2004

VOCATIONAL/ TRADE
COURSE

TERTIARY ST. PAUL UNIVERSITY PHILIPPINES

ASSOCIATE IN HEALTH
SCIENCE EDUCATION 2004 2006

PINES CITY COLLEGES

BACHELOR OF
SCIENCE IN NURSING 2008 2006 2008

GRADUATE STUDIES

(Continue on separate sheet if necessary)

Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
29. DATE OF LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
UNDER SPECIAL LAWS/ CES/ CSEE NUMBER DATE OF
CONFERMENT
RELEASE

NURSING LICENSURE EXAMINATION 75.00% 06/06-07/2009 TUGUEGARAO CITY 0580378 11/09/2009

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work) GOV'T
SERVICE
30. INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY SALARY GRADE
(mm/dd/yyyy) MONTHLY & STEP STATUS OF
SALARY INCREMENT APPOINTMENT
(Write in full) (Write in full) (Format "00-0")
From To
(Yes / No)

(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

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

(Continue on separate sheet if necessary)

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

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

ADVANCE COMMUNITY NURSING PRACTICE USING IMCI PERSPECTIVE 07/21/2007 07/21/2007 2 JEROME B. MANSIBANG

THIRD CORDILLERA STUDENT NURSES' CONGRESS 03/08/2008 03/08/2008 5 MARY GRACE LACANARIA RN,PhD

SAFE NURSING PRACTICE 09/27/2009 09/27/2009 4 HILDEGARDA HIPOLITO RN,MSN,MAN,MPh

FIRST AID TRAINING (STANDARD)

04/12/2010 04/15/2010 32 PHILIPPINE NATIONAL REDCROSS (CAGAYAN CHAPTER)

BASIC LIFE SUPPORT (CPR TRAINING FOR HEALTHCARE PROVIDER) 04/16/2010 04/17/2010 16 PHILIPPINE NATIONAL REDCROSS (CAGAYAN CHAPTER)

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

COMPUTER LITERATE

(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.

VICTORIA B. BAWAYAN PCC BAGUIO CITY ID picture taken within

JUANITA Y. NIALLA PCC BAGUIO CITY the last 6 months

JANE TAMARAY TCPGH TUGUEGARAO CITY

3.5 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
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

03148148
COMMUNITY TAX CERTIFICATE NO.

TUGUEGARAO CITY
ISSUED AT SIGNATURE (Sign inside the box)

08/06/2010 August 6, 2010

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

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