CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

Print legibly. Mark appropriate with “√” and use separate sheet if necessary.
1. CS ID (to be filled by CSC)
No.
I. PERSONAL INFORMATION

2. SURNAME S A N T O S
FIRST NAME R O N A L D O
3. NAME EXTENSION (e.g. Jr.,
MIDDLE NAME Q U I N T E R O Sr.)
Blk 7 Lot 12 Queensville Subd Bagumbong
4. DATE OF BIRTH (mm/dd/yyyy) January 28, 1978 16. RESIDENTIAL ADDRESS
Caloocan City
5. PLACE OF BIRTH Balanga, Bataan
6. SEX Male Female
7. CIVIL STATUS Single Widowed ZIP CODE 1421
Married Separated 17. TELEPHONE NO. 09491343038
Blk 7 Lot 12 Queensville Subd Bagumbong
Annulled Others, 18. PERMANENT ADDRESS Caloocan City
specify

8. CITIZENSHIP Filipino
9. HEIGHT (m) 165
10. WEIGHT (kg) 58 ZP CODE 1421
11. BLOOD TYPE “O” 19. TELEPHONE NO. 09491343038
12. GSIS ID NO. N/A 20. E-MAIL ADDRESS (if any) Ronaldosantos28@yahoo.com
13. PAG-IBIG ID NO. 316288771312 21. CELLPHONE NO. (if any) 09491343038
14. PHILHEALTH NO. 70250384910 22. AGENCY EMPLOYEE NO.
15. SSS NO. 0218833250 23. TIN 253535841
II. FAMILY BACKGROUND
24. SPOUSE’S DATE OF BIRTH
N/A 25. NAME OF CHILD (Write full name and list all)
SURNAME (mm/dd/yyyy)
FIRST NAME Rojella D Santos April 9, 2005
MIDDLE NAME Majeron D Santos March 27, 2007
OCCUPATION N/A Jett Ronaldo D Santos February 8, 2011

EMPLOYER/BUS. NAME

BUSINESS ADDRESS

TELEPHONE NO. N/A

(Continue on separate sheet if necessary)

26. FATHER’S SURNAME Santos January 1, 1945

FIRST NAME Rolando
MIDDLE NAME Santos
27. MOTHER’S MAIDEN NAME January 31, 1941
SURNAME Quintero
FIRST NAME Violeta
MIDDLE NAME Medina (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY Balanga Elementary School N/A 1990 Graduated 1984 1990 N/A

SECONDARY Tomas Del Rosario Academy N/A 1994 Graduated 1990 1994 N/A

VOCATIONAL/
N/A N/A N/A N/A N/A N/A N/A
TRADE COURSE

Bachelor of
Science in N/A
COLLEGE Our Lady of Fatima University 1999 Graduated 1994 1999
Physical
Therapist
GRADUATE
STUDIES
Our Lady of Fatima University Doctor of Medicine 2005 Graduated 2001 2005 N/A
(Continue on separate sheet if necessary)
CS FORM 212 (Revised 2005) Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
29. DATE OF LICENSE NO. (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/BAR) RATING EXAMINATION/ PLACE OF EXAMINATION/CONFERMENT DATE OF
NUMBER
UNDER SPECIAL LAWS/CES/CSEE CONFERMENT RELEASE
Board Examination for Physical Sept
Therapist 78% August 2000 Manila 10181
2000
March
Physician Licensure Exam 76% February 2007 Manila 109632
2007

V. WORK EXPERIENCE (Include private employment. Start from your current work)

30. INCLUSIVE DATES DEPARTMENT/ AGENCY/ SALARY GRADE & GOV’T

(mm/dd/yyyy) POSITION TITLE MOTHLY STATUS OF
OFFICE/ COMPANY STEP INCREMENT SERVICE
(Write in full) SALARY (Format “00-0” APPOINTMENT
(Write in full) (Yes/ No)
From To
May 31,
Present Police Senior Inspector Philippine National Police 35,312 23 Temporary Yes
2012
September May 8,
Medical Officer 3 Eastern Bicol Medical Center 26,000 18 Permanent Yes
8, 2008 2012

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2005), Page 2 of 4
VII. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

31. INCLUSIVE DATES NUMBER

NAME & ADDRESS OF ORGANIZATION (mm/dd/yyyy) OF POSITION/ NATURE OF WORK
(Write in full) From To HOURS
N/A N/A N/A N/A N/A

/ / /

/ / / /

/ / / /

/ / / /

/ / / /

(Continue on separate sheet if necessary)

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

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

PUBLIC SAFETY OFFICER BASIC COURSE 12/17/2012 1/22/2014 1,920 National Police College
SOCO COURSE 8/18/2013 12/10/2013 364 CRIME LAB. CAMP CRAME, QUEZON CITY

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

Playing Badminton N/A Phil. Medical Association

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 20Page 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 has
immediate supervision over you in the Office, Bureau or Department where you will be appointed? If YES, give details:

b. Within the fourth degree (for Local Government Employees):

Appointing authority or recommending authority where you will be appointed? YES NO
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 regulation by any court
YES NO
or tribunal?
If YES, give details:

39. Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped YES NO
from the rolls, dismissal, termination, end of term, finished contract, AWOL or phased out, in the public or
If YES, give details:
private sector?

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:
YES NO
a. Are you a member of any indigenous group? If YES, please specify: Ibaloi
YES NO
b. Are you differently abled? If YES, please specify:

c. Are you a solo parent? YES NO

If YES, please specify:

42. REFERENCES (Person not related by consanguinity of affinity to applicant/ appointee)

NAME ADDRESS TEL. NO

PSI Micheal Nick Sarmiento MD Proj. 8, Quezon City 09228680700

ID picture taken within

DR Arman Jefferson Espinola

Virac, Catanduanes 09215194147 the last 6 months
3.5 cm. X 4.5 cm.
(passport size)

PSI Von Eric Gualberto

Calamba, Laguna 09289757407
43. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and complete statement Computer generated or xeroxox
copy of picture
pursuant to the provisions of pertinent rules and regulation of the Republic of the Philippines. is not acceptable

I also authorize the agency head/ authorized representative to verify/ validate the contents stated herein. I trust that this information
shall remain confidential.

37040738

COMMUNITY TAX CERTIFICATE NO.

Caloocan, City
ISSUED AT SIGNATURE (Sign inside the box)

January 03,2016 January 28, 2014

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

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