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.
by
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 BASHER

ANNA NORLAYLA S Duana NAME EXTENSION (JR., SR)

F
FIRST NAME

MIDDLE NAME

3. DATE OF BIRTH
WAHAB

12/16/1993 e Fili l tur

e
16. CITIZENSHIP
(mm/dd/yyyy)

O
✘

Si
M p
a pin Citizali ✘

tid
4. PLACE OF BIRTH KAPANTARAN MARINAUT,MAR If holder of dual citizenship, Pls. indicate country:

o ens
please indicate the details.

a
5. SEX ✘

6 CIVIL STATUS ✘
n
al
o r 17. RESIDENTIAL ADDRESS N/A
i za N/A

ra
House/Block/Lot No. Street

hgl
e ri
AGAMA, APARTMENT CELDRAN

hip
TUBOD

r tio
Subdivision/Village Barangay

w
ILIGAN CITY LANAO DEL NORTE

la
7. HEIGHT (m) 1.6 M

e
City/Municipality Province

e e
8. WEIGHT (kg) 53 KG ZIP CODE 9200

e
18. PERMANENT ADDRESS 147
t n N/A

e
9. BLOOD TYPE 'O''

r/
House/Block/Lot No. Street

td
N/A KAPANTARAN MARINAUT
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121197983751

d
s:
MARAWI CITY LANAO DEL SUR

e
City/Municipality Province
12. PHILHEALTH NO. 20-252439439-3 ZIP CODE 9700

13. SSS NO. 08-2753657-9 19. TELEPHONE NO. NONE

14. TIN NO.

15. AGENCY EMPLOYEE NO.

701-328-129-000
N/A d 20. MOBILE NO.

21. E-MAIL ADDRESS (if any)

09051721699

basha12161993@gmail.com
II. FAMILY BACKGROUND
DATE OF BIRTH
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
(mm/dd/yyyy)
NAME EXTENSION (JR., SR) N/A
FIRST NAME N/A
MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME AROBA
NAME EXTENSION (JR., SR)
FIRST NAME BASHER
MIDDLE NAME BUAYA

25. MOTHER'S MAIDEN NAME TUMANINA

SURNAME AROBA

FIRST NAME BUKAD

MIDDLE NAME WAHAB (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE UNITS
YEAR
ACADEMIC
LEVEL (Write in full) EARNED
GRADUATED
HONORS
(Write in full) (if not RECEIVED
From To
graduated)
SENATOR NINOY AQUINO COLLEGE
ELEMENTARY
FOUNDATION
ELEMENTARY 2000 2007 GRADUATED 2007 N/A
VOCATIONAL / DANSALAN COLLEGE FOUNDATION
SECONDARY
INCORPORATED
SECONDARY EDUCATION 2007 2011 GRADUATED 2011 N/A

N/A N/A N/A N/A N/A N/A N/A

COLLEGE TRADE SOUTHWESTERN UNIVERSITY BS-PHARMACY 2011 2015 GRADUATED 2015 N/A
COURSE
GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE July 24, 2019

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
REGISTERED PHARMACIST 75% 3/15/2017 ST.JUDE, MANILA CITY 73969 12/16/2020

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE
"TypeWork
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached equation here."
Experience sheet. GOV'T
SALARY/ JOB/ SERVICE
28. INCLUSIVE DATES PAY GRADE (if
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY applicable)& STATUS OF
(Write in full/Do SALARY STEP (Format APPOINTMENT
not abbreviate) (Write in full/Do not abbreviate) "00-0")/
From To INCREMENT
(Y/
N)
CONTRACT OF
5/10/2017 PRESENT PHARMACIST THE GENERICS PHARMACY 15,OOO N/A SERVICE N

(Continue on separate sheet if necessary)

SIGNATURE DATE July 24, 2019

CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (Write in
full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

N/A N/A N/A N/A N/A

(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
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) From To Technical/etc)

ALIGNING PHARMACY PRACTICE WITH CURRENT

REGULATORY REFORMS
7/29/2017 7/29/2017 8 HOURS TECHNICAL LEONILA M, OCAMPO, RPH

2017 PPHA REGIONAL CONFERENCE 11/28/2018 11/29/2017 8 HOURS TECHNICAL YOLANDA ROBLES, RPH

PHARMACY READY FOR THE DEMAND OF IMPROVED

AND EXPANDED PHARMACY SERVICES
4/12/2018 4/12/2018 8 HOURS TECHNICAL LEONILA M, OCAMPO, RPH
PHARMACIST AS ADVOCATES, PROTECTORS AND
EDUCATORS OF HEALTH AND ENVIRONMENT 9/28/2018 9/28/2018 8 HOURS TECHNICAL MAGLYN YOUNG-TIU,RPH
SOCIETY
UNIFIED LICENCING SEMINAR 10/25/2018 10/25/2018 8 HOURS TECHNICAL MARIA CECEILIA C. MATIENZO

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 33.
(Write in full) (Write
in full)
PHILIPPINE PHARMACIST
COMPUTER LITERATE N/A
ASSOCIATION
SUPERVISING

READING

(Continue on separate sheet if necessary)

SIGNATURE DATE July 24, 2019

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 theof bureau or office or to the person who has immediate supervision over you in the
chief
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
YES ✘ NO
regulation 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 If YES, give details:
phased out (abolition) in the public or private sector? ________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year
YES ✘ NO
(except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
the last 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
a.
items:
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
DR. NORMALLAH DIMALOTANG-ALONTO TUBOD, ILIGAN CITY 0999-991-6810 3.5 cm. X 4.5 cm
(passport size)

KAREN AYOP TUBOD, ILIGAN CITY 9324875899 With full and handwritten
name tag and signature over
printed name
ANIRA S. MAROHOMSALIC MALABANG, LANAO DEL SUR 0906-0256254
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct or photocopied picture
is not acceptable
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 PHOTO
filing of 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: PRC LICENSE

ID/License/Passport No.: 0073969

Signature (Sign inside the box)
July 24, 2019
Date/Place of Issuance: 3/30/2017, CAGAYAN DE ORO
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