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CS Form No.

212
Revised 2017

PERSONAL DATA SHEET


WARNING: Any misinterpretation 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 DIAZ-SAMSON
FIRST NAME RINA n/a

MIDDLE NAME MALLARI


3. DATE OF BIRTH
2/20/1978 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by by

birth naturalization
4. PLACE OF BIRTH Lubao, Pampanga If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female
6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS
House/Block/Lot No. Street
Widowe Separat
San Roque Dau I
d ed
Other/s: Subdivision/Village Barangay
7. HEIGHT (m) 1.63 Lubao Pampanga
City/Municipality Province
8. WEIGHT (kg) 62 ZIP CODE C-2005

9. BLOOD TYPE B 18. PERMANENT ADDRESS San Roque Dau I


House/Block/Lot No. Street

10. GSIS ID NO. 02004220008


Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1400-0057-9351 Lubao Pampanga


City/Municipality Province

12. PHILHEALTH NO. 07-025154575-6 ZIP CODE C-2005

13. SSS NO. 02-324-0571-6 19. TELEPHONE NO. n/a

14. TIN NO. 238-044-088 20. MOBILE NO. 09257052320

15. AGENCY EMPLOYEE NO. PAO-00873-2013 21. E-MAIL ADDRESS (if any) rhines022078@yahoo.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME Samson 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME Rodrigo Peter Jr. Severina Chrystela Diaz Samson 8/5/2002
MIDDLE NAME Armas Sethiel Chrystan Diaz Samson 11/23/2010
OCCUPATION Manager (Maintenance Department) Sebastian Chrystoph Diaz Samson 6/20/2013
EMPLOYER/BUSINESS NAME Pradera Verde
BUSINESS ADDRESS Prado Siongco, Lubao, Pampanga
TELEPHONE NO. 9165909606
24. FATHER'S SURNAME Diaz
FIRST NAME Robertito n/a

MIDDLE NAME Vitug


25. MOTHER'S MAIDEN NAME

SURNAME Mallari
FIRST NAME Remedios
MIDDLE NAME Marucut (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND


NAME OF SCHOOL HIGHEST LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
BASIC EDUCATION/DEGREE/COURSE UNITS ACADEMIC
LEVEL (Write in EARNED
GRADUATED
HONORS
(Write in full)
full) (if not graduated) RECEIVED
From To
ELEMENTARY Lubao Central Elementary School Primary Education 1984 1990 n/a 1990 n/a
VOCATIONAL
SECONDARY / Sacred Heart Academy Highschool 1990 1994 n/a 1994 2nd Hon.Men.

Megabyte Computer Technology 03/1992 06/1992 1992


Stenography/Typewriting n/a n/a
Research Center 03/1991 05/1991 1991
TRADE
COLLEGE
COURSE University of Santo Tomas B.S. Pharmacy 1994 1998 n/a 1998 n/a

Award of
Excellence;
Topnotcher of all
areas of
GRADUATE STUDIES University of the Assumption Master in Public Administration 2004 2006 n/a 2006 comprehensive
exam; All- time
topnocher of
gstat final exam

(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
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity
3/28/2012/
RA 1080 - Bar Exam 80.453% University of Santo Tomas, Manila 61714 n/a
11/2011
RA 1080 - Pharmacist Board Exam 87.820% 7/25-26/1998 University of the East, Manila 41390 2/20/2018

Career Service Professional 91.080% 1/29/2004 CSC Regional Office III n/a n/a
CSC Brightest for the Bureaucracy Program
95.000% 2/5/2004 CSC Regional Office III n/a n/a
of the Philippines

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

3/16/2015 Present Public Attorney II Public Attorney's Office n/a Temporary Yes

7/9/2012 3/15/2015 Public Attorney I Public Attorney's Office n/a Temporary Yes

City College of San Fernando


6/13/2015 10/30/2015 Professor n/a Contractual No
Pampanga

11/11/2008 3/31/2012 Pharmacist EDES Drugstore n/a Permanent No

Asian College of Science and


6/5/2006 4/30/2011 Faculty Head n/a Permanent No
Technology
2/1/2005 10/30/2011 Pharmacist Coronel's Pharmacy n/a Contractual No

6/1/2006 10/30/2006 Instructor University of the Assumption n/a Contractual No

Asian College of Science and


10/30/2005 4/30/2006 Instructor III n/a Contractual No
Technology
5/5/2004 10/1/2005 Manager Rody-Rina General Merchandise n/a Permanent No

1/3/1999 5/3/2004 Manager Tito & Remy General Merchandise n/a Permanent No

(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

Philippine Pharmacists Association 03/04/1999 Present n/a Member

Integrated Bar of the Philippines 03/03/2012 Present n/a Member

(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) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To

(Resource Person) St. Mary's Academy,


Gender and Development Seminar 10/14/2017 5 Technical
Guagua
6th MCLE Accredited National Convention of Public Attorneys 9/19/2017 9/23/2017 36 Technical Public Attorney's Office
Training Seminar on the Revised Guidelines for Continuous Trial of Criminal
5/25/2017 5/25/2017 6 Technical Supreme Court of the Philippines
Cases
Managerial/
Seminar on the Revised PAO Operations Manual & Code of Conduct 3/20/2017 3/22/2017 22 Public Attorney's Office
Supervisory
(Resource Person) Bureau of Jail
Seminar on Paralegal Monitoring, Mentoring & Supervision 12/5/2016 12/5/2016 4 Technical
Management & Penology
Training of Trainers (TOT) on the Formulation of Comprehensive Local (Resource Person) Juvenile Justice and
9/13/2016 9/15/2016 8 Technical
Juvenile Intervention Program (CLIP) cum Planning Workshop Welfare Committee, Region II
Training towards Accountability, Capability Building & Empowerment of Public Managerial/
12/7/2015 12/7/2015 8 Public Attorney's Office
Attorneys Supervisory
Public Attorney's Office and EU Phil. Justice
Training for the Newly Appointed Public Attorneys 9/29/2015 10/1/2015 24 Technical
Support Programme
04/29/2015 04/29/2015 Technical CPRM Consultants
2nd Validation Workshop of the Study of ADB Under TA 8006 8
Managerial/ (Resource Person) Pampanga Police
02/18/2015 02/18/2015
Orientation Seminar on Laws for the Advancement of Women 5 Supervisory Provincial Office
5th MCLE Accredited National Convention of Public Attorneys 10/13/2014 10/17/2014 36 Technical Public Attorney's Office
Managerial/
I am Youth, I am Drug-Free: Leading the Path to the Right Way 10/1/2014 10/1/2014 5 (Resource Person) Holy Angel University
Supervisory
8/11/2014 8/13/2014 Technical University of the Philippines Law Center
Mandatory Continuing Legal Education Program 14
SC Associate Justice Roberto Abad/IBP
Judicial Affidavit Rule & Other Reforms 11/30/2012 11/30/2012 Technical
4 Pampanga Chapter
Managerial/
Seminar Workshop on Codes & References for Public Attorney's Ofice 9/20/2012 9/21/2012 Public Attorney's Office
16 Supervisory
Effective and Efficient Teaching Managerial/ Pampanga Association of Technical
Strengthening & Enhancing SkillsMethodology
Competency for Global Competitiveness 05/05/2009 05/05/2009
8 Supervisory Vocational Institutions
Teaching Methodology
02/10/2009 02/10/2009 Technical Asian College of Science and Technology
8
Managerial/
09/22/2008 09/22/2008 Asian College of Science and Technology
Leadership Training Workshop 8 Supervisory
Teamwork and Basic Work Values Managerial/
06/13/2008 06/13/2008 Asian College of Science and Technology
8 Supervisory
Managerial/
06/10/2008 06/10/2008 Asian College of Science and Technology
Business Writing & Communication 8 Supervisory
(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
(Write in full)
in full)

Stenography
Employee of the Year (ACSAT Pamp. 2009) Philippine Pharmacists Association

Typewriting
Employee-Writer of the Year (ACSAT Pamp. 2008) Integrated Bar of the Philippines

PC Operations Teacher of the Year (ACSAT Pamp. 2009)


Creative Writing

(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 ✘
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘
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? Only Separation by Resignation
________________________________
________________________________
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
Atty. Hernando B. Perez University of Batangas, Lipa City 9228592739 3.5 cm. X 4.5 cm
(passport size)

Dean Domingo Navarro AUF, Angeles City 9276265986 With full and handwritten
name tag and signature over
printed name
Atty. Marianne Beltran-Angeles AUF, Angeles City 9175368353
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: PAO Employee ID

ID/License/Passport No.: PAO-00873-2013


Signature (Sign inside the box)

Date/Place of Issuance: 06/15/2015, Quezon 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