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 ARCEGA
NAME EXTENSION (JR., SR)
FIRST NAME ROMAR RICO

MIDDLE NAME HORNILLA

3. DATE OF BIRTH
1/10/1997 16. CITIZENSHIP Filipino
(mm/dd/yyyy) Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH If holder of dual citizenship, please Pls. indicate country:

5. SEX Male Female indicate the details.

Single Married 17. RESIDENTIAL ADDRESS Block 40 Extension

6 CIVIL STATUS
House/Block/Lot No. Street
Widowed Separated
El, Sitio Dumantay
Other/s: Subdivision/Village Barangay
Batangas City Batangas
7. HEIGHT (m) 5''6 City/Municipality Province

8. WEIGHT (kg) 50 4200

ZIP CODE
18. PERMANENT ADDRESS Block 40 Extension
9. BLOOD TYPE O NEGATIVE House/Block/Lot No. Street
El, Sitio Dumantay
10. GSIS ID NO. N/A Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121221047123 Batanga City Batangas

City/Municipality Province

12. PHILHEALTH NO. 09-250149508-7 4200

ZIP CODE

13. SSS NO. 34-6383681-8 19. TELEPHONE NO. N/A

14. TIN NO. 621-814-315 20. MOBILE NO. 09683732635
15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME ARCEGA

NAME EXTENSION (JR., SR)
FIRST NAME BERT
MIDDLE NAME LEYNES

25. MOTHER'S MAIDEN NAME

SURNAME HORNILLA

FIRST NAME MARISSA

MIDDLE NAME SALIGAO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

JOSE C. PASTOR MEMORIAL ELEMENTARY

ELEMENTARY
SCHOOL
PRIMARY 2004 2010 GRADUATE 2010

SECONDARY BATANGAS NATIONAL HIGH SCHOOL High School 2010 2014 GRADUATE 2014
VOCATIONAL /
TESDA- Regional Training Center-CALABARZO VOCATIONAL / Pipefitting (NC II) 2016 2016 GRADUATE 2016

COLLEGE Golden Gate Colleges Bachelor of Science in Nursing 2018 2022 GRADUATE 2022 EBD-SCHOLARSHIP

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE
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 Date of
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE / Validity
CONFERMENT

November 12 & 13, 1/10/2026

Philippine Nurse Licensure Examination 78.2 Lucena City 0955283
2022

(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
INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
28. POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHL STATUS OF
(Write in full/Do not (Write in applicable)& STEP
Y (Format "00-0")/ APPOINTMENT
From abbreviate) full/Do not abbreviate) SALAR
To INCREMENT
Y

School Nurse Stonyhurst Southville International School On- Call

Clinic Nurse Animal Bite Center On- Call

Shift Nurse
Company Nurse JG Summit Petrochemicals Group Reliever
Emergency Department / Batangas
3/3/2023 Present Job Order Nurse Medical Center Job Order

(Continue on separate sheet if necessary)

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

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED

INCLUSIVE DATES OF
ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
3 NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
Technical/etc)
From To
Coronavirus (COVID-19)for Nursing Professionals
9/4/2020 9/4/2020 8 HOURS
Highlights of CoViD-19 Interim Guidelines in Recalibrating Response Strategies
12/17/2020 12/17/2020 8 HOURS
mhGAP Intervention Guide: Linking the Gap towards Mental Wellness
5/5/2021 5/5/2021
8 HOURS
5th DOST Graduate Course on Critical Care and End of Life Care in the Emergency
4/9/2021 5/9/2021 16 HOURS
Department
Nursing in the World of Health Care: Maximizing Care of Clients in the Acute Biologic
10/ 28/ 2021 10/ 28/ 2021 8 HOURS
Crisis and Emergency Standards during Pandemic
Senior Citizen’s Act
11/9/2021 11/9/2021 6 HOURS
Developing Communities that Protect Children from all Forms of Harm
11/19/2021 11/19/2021 6 HOURS
Basics of Life Support Philippine Red Cross - Batangas Chapter
11/23/2021 11/23/2021 8 HOURS
Ethical Issues and the Practice of Nursing Amidst Pandemic
11/ 24/ 2021 11/ 24/ 2021 6 HOURS
Living with Purpose: Importance of Spirituality in ProvidingOptimal
11/ 25/ 2021 11/ 25/ 2021 6 HOURS
Nursing Care
Readiness for Environmental Emergency Response Philippine Red Cross - Batangas Chapter
12/3/2021 12/3/2021 6 HOURS
Competency Development Program on Basic Advance IV Therapy Batangas Medical Center
02/27/2023 3/1/2023 24 HOURS
Basics of Life Support Batangas Medical Center
3/10/2023 3/10/2023 8 HOURS
Patient Safety Capacity Building Batangas Medical Center
04/ 28/ 2023 04/ 28/ 2023 8 HOURS
PRIMERA SERIE DE CARDIO-ONCOLOGIA Makati Medical Center
11/ 28/ 2023 11/ 29/ 2023 16 HOURS
CONQUERING HORIZONS: POSSIBILITIES AND GROWTH IN EMERGENCY MEDICINE De La Salle University Medical Center
8/4/2024 9/4/2024 16 HOURS

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. (Write in full) 33. (Write in
full)

Cooking

Playing Online Game

(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:

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 by any YES NO
court or tribunal? If YES, give details:

37. Have you ever been separated from the service in any of the following modes: resignation, retirement, YES NO
dropped from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in the If YES, give details:
public or private sector?
38. a. Have you ever been a candidate in a national or local election held within the last year (except Barangay YES NO
election)? If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last election to YES NO
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
ANDREW GONZALES SAN PASCUAL, BATANGAS 9175162616 4.5 cm. X 3.5 cm
(passport size)
SEMIRA ANNE PANGANIBAN BANABA CENTER, BATANGAS 9778237804
Computer generated or
photocopied picture is
WENELIZA ATRACTIVO LACANDOLA SARIAYA, QUEZON 9190059423 not acceptable
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and 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: PHILHEALTH

ID/License/Passport No.: 09-250149508-7

Signature (Sign inside the box)

Date/Place of Issuance: Batangas 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