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

I. PERSONAL INFORMATION
2. SURNAME DELUTE
NAME EXTENSION (JR., SR)
FIRST NAME ANABELLE

MIDDLE NAME ASILO

3. DATE OF BIRTH
(mm/dd/yyyy) 12/16/1976 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH DAVAO CITY, DAVAO DEL SUR If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS NO. 2 DEL ROSARIO ST.
Widowed Separated House/Block/Lot No. Street
RAFAEL CASTILLO
Other/s:
Subdivision/Village Barangay
DAVAO CITY DAVAO DEL SUR
7. HEIGHT (m) 1.54
City/Municipality Province
8. WEIGHT (kg) 56 ZIP CODE 8000

18. PERMANENT ADDRESS NO.2 DEL ROSARIO ST.

9. BLOOD TYPE O
House/Block/Lot No. Street
RAFAEL CASTILLO
10. GSIS ID NO. N/A
Subdivision/Village Barangay
DAVAO CITY DAVAO DEL SUR
11. PAG-IBIG ID NO. 121114432252
City/Municipality Province

12. PHILHEALTH NO. 16-200416806-2 ZIP CODE 8000

13. SSS NO. 09-1719283-6 19. TELEPHONE NO. N/A

14. TIN NO. 927-686-539 20. MOBILE NO. 09079155053

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) delute_anabelle@yahoo.com

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME DELUTE 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyy
NAME EXTENSION (JR., SR) KALEL CLARK A. DELUTE
FIRST NAME JUNIEL 02/13/2006

MIDDLE NAME DELFINO ANAKIN EXEQUIEL A. DELUTE 07/18/1999

OCCUPATION TEACHER

EMPLOYER/BUSINESS NAME SPED BANGKAL HIGH SCHOOL

BUSINESS ADDRESS KILOMETER 9 BANGKAL, DAVAO CITY

TELEPHONE NO. 299-2226

24. FATHER'S SURNAME ASILO
NAME EXTENSION (JR., SR)
FIRST NAME ABRAHAM
MIDDLE NAME BONITE
25. MOTHER'S MAIDEN NAME

SURNAME SEMBLANTE

FIRST NAME DONATILA

MIDDLE NAME ILUSTRESIMO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL HIGHEST LEVEL/
26. BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE UNITS YEAR
LEVEL (Write in EARNED GRADUATED
(Write in full)
full) (if not graduated)
From To
ELEMENTARY SAN JUAN ELEMENTARY SCHOOL ELEMENTARY 1986 1992 1992

SECONDARY
VOCATIONAL / HOLY CROSS OF AGDAO HIGH SCHOOL HIGH SCHOOL 1992 1996 1996

TECARRO COLLEGE FOUNDATION, INC. HEALTH CARE NCII 2016 2017 2017
TRADE
BACHELOR OF SCIENCE IN
COURSE
COLLEGE UNIVERSITY OF MINDANAO 1998 2010 2010
MANAGEMENT ACCOUNTING
GRADUATE STUDIES N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 4/2/2020

CS FORM 212 (Revised 2017), Page

AL DATA SHEET
Experience Sheet shall cause the filing of administrative/criminal case/s against the person concerned.

S) BEFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

by naturalization
Pls. indicate country:

DEL ROSARIO ST.

Street
RAFAEL CASTILLO
Barangay
DAVAO DEL SUR
Province
8000

DEL ROSARIO ST.

Street
RAFAEL CASTILLO
Barangay
DAVAO DEL SUR
Province

8000

N/A

09079155053

delute_anabelle@yahoo.com

DATE OF BIRTH (mm/dd/yyyy)

02/13/2006

07/18/1999

(Continue on separate sheet if necessary)

SCHOLARSHIP/
ACADEMIC
HONORS RECEIVED
nue on separate sheet if necessary)

4/2/2020

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

N/A

(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
28. INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
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)

08/24/2018 PRESENT WARD AIDE 1 SOUTHERN PHILIPPINES MEDICAL CENTER 409.09/DAY N/A JOB ORDER NO

2/8/2010 08/23/2018 ADMINISTRATIVE AIDE 1 SOUTHERN PHILIPPINES MEDICAL CENTER 409.09/DAY N/A JOB ORDER NO

1/1/2004 07/31/2010 AUXILIARY SERVICE WORKER CITY GOVERNMENT OF DAVAO 5,670.00 N/A JOB ORDER NO

1/7/2003 12/31/2003 COMMUNITY AFFAIRS WORKER CITY GOVERNMENT OF DAVAO 5,061.00 N/A JOB ORDER NO

11/16/2001 06/30/2003 CLERICAL AIDE CITY GOVERNMENT OF DAVAO 5,061.00 N/A JOB ORDER NO
 (Continue on separate sheet if necessary)

SIGNATURE DATE 02/04/2020

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

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
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

BASIC LIFE SUPPORT TRAINING/HEALTHCARE PROVIDER 09/16/2019 09/17/2019 16 TECHNICAL SOUTHERN PHILIPPINES MEDICAL CENTER

PROVIDING SERVICE BEYOND SATISFACTION 04/25/2019 11/2/2019 8 FOUNDATION SOUTHERN PHILIPPINES MEDICAL CENTER

ORIENTATION ON DATA PRIVACY LAW 11/2/2019 10/24/2019 4 FOUNDATION SOUTHERN PHILIPPINES MEDICAL CENTER

SEMINAR ON HEALTH LIFESTYLE 10/24/2018 10/26/2018 8 FOUNDATION SOUTHERN PHILIPPINES MEDICAL CENTER
INTERMITTENT WARD NURSING TRAINING PROGRAM FOR NURSING
2/2/2018 06/16/2018 160 TECHNICAL SOUTHERN PHILIPPINES MEDICAL CENTER
ATTENDANTS
EIGHTY (80) HOUR ON THE JOB TRAINING ON HEALTH CARE SERVICES AND
CITY SOCIAL SERVICES AND DEVELOPMENT
CAREGIVING SERVICES NC II-LINGAP CENTER FOR MENTALLY CHALLENGED 07/29/2017 3/9/2017 80 TECHNICAL
OFFICE -- CITY OF DAVAO
CHILDREN
EIGHTY (80) HOUR ON THE JOB TRAINING ON HEALTH CARE SERVICES AND CITY SOCIAL SERVICES AND DEVELOPMENT
04/23/2017 4/6/2017 80 TECHNICAL
CAREGIVING SERVICES NC II OFFICE -- CITY OF DAVAO
TECHINICAL EDUCATION AND SKILLS
NC II IN HEALTH CARE SERVICES (#16112402044920) 11/29/2016 11/29/2016 8 FOUNDATION
DEVELOPMENT AUTHORITY

(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 in
(Write in full)
full)
JUNIOR PHILIPPINES ASSOCIATION OF
COMPUTER LITERATE N/A
MANAGEMENT ACCOUNTING
TYPING
RECORD KEEPER, FILING, RETRIEVING,
SORTING OF RECORDS
DANCING

SWIMMING

ARTISTRY AND CRAFTS

(Continue on separate sheet if necessary)

SIGNATURE DATE 02/04/2020

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
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? ________________________________
________________________________
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
SOUTHERN PHILIPPINES MEDICAL 227-2731 the last 6 months
LANI P. PALER, MPA, MBA-HA CENTER, DAVAO CITY LOC 4605 3.5 cm. X 4.5 cm
(passport size)
SOUTHERN PHILIPPINES MEDICAL 227-2731
CATALINA E. BERSABAL, MPA CENTER, DAVAO CITY LOC 4219 With full and handwritten
name tag and signature over
SOUTHERN PHILIPPINES MEDICAL printed name
MINA P. RICO, RN, MAN CENTER, DAVAO CITY
227-2731
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: DRIVER'S LICENSE

ID/License/Passport No.: L02-06-007953

Signature (Sign inside the box)
02/04/2020
Date/Place of Issuance: 12/13/2017 DAVAO 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