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
1. CS ID ABBREVIATE.
(Do not fill up. For CSC use only)

I. PERSONAL INFORMATION
2. SURNAME BUMATAY
NAME EXTENSION (JR., SR)
FIRST NAME KATE DANICA
MIDDLE NAME SINGIAN
3. DATE OF BIRTH
(mm/dd/yyyy) 12/4/1998 16. CITIZENSHIP Filipino

4. PLACE OF BIRTH San Fernando La Union If holder of dual citizenship, Pls. indicate country:
5. SEX Female please indicate the details.

17. RESIDENTIAL ADDRES Purok 6

6 CIVIL STATUS Single
House/Block/Lot No. Street

Nagrebcan

Subdivision/Village Barangay

Luna La Union
7. HEIGHT (m) 5'3
City/Municipality Province

8. WEIGHT (kg) 53 ZIP CODE 2518

18. PERMANENT ADDRESS Purok 6

9. BLOOD TYPE A
House/Block/Lot No. Street

Nagrebcan
10. GSIS ID NO.
Subdivision/Village Barangay

Luna La Union
11. PAG-IBIG ID NO. 121307179992
City/Municipality Province

12. PHILHEALTH NO. 052506766095 ZIP CODE 2518

13. SSS NO. 01-3049078-4 19. TELEPHONE NO.

14. TIN NO. 64-256-268-00000 20. MOBILE NO. 09567852624

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any katedanica.bumatay04@gmail.com

II. FAMILY BACKGROUND

DATE OF BIRTH
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all)
(mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER

BUSINESS ADDRESS

TELEPHONE NO.

24.FATHER'S SURNAME Bumatay

NAME EXTENSION (JR., SR)
FIRST NAME Danilo
MIDDLE NAME Singian
25. MOTHER'S MAIDEN NAME

SURNAME Bumatay

FIRST NAME Raquelita

MIDDLE NAME Singian (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY San Nicolas Academy 7/6/2004 2010

SECONDARY San Nicolas Academy 7/6/2010 ### 2015

COLLEGE Lorma Colleges Bachelor in Medical Laboratory Science 8/6/2015 ### 2021
GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE #NAME? DATE September 14, 2022

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
Philippine Regulation Commission Licensure
79.4 8/20/2022 Baguio City
Examination for MedicalTechnologist

(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)

(Continue on separate sheet if necessary)

SIGNATURE #NAME? DATE September 14, 2022

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. 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
Certificate of participation for outstanding participation during the Enrichment Lecture in Clinical
12/1/2017 12/1/2017 8 hours Sir Ryan Mostoles
Chemistry

Medical Technology Internship Program 3/1/2021 8/31/2021 1080 hours Lorma Collges

(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)

Playing Guitar Power Dance Competition Red Cross Member

Dancing

Reading

Volleyball

(Continue on separate sheet if necessary)

SIGNATURE #NAME? DATE September 14, 2022

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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
________________________________

35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court?
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 court or tribunal?
If YES, give details:
________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation,
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
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before 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?
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?
If YES, please specify:
b. Are you a person with disability?
If YES, please specify ID No:
c. Are you a solo parent?
If YES, please specify ID No:

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAME ADDRESS TEL. NO.

Mrs. Josephine C. Milan, RMT, MSMT Irisan, Baguio City 09258071099

Erannie Lynn Rosario D. Jasmin, MEd San Fernando, La Union 090727002500

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.) #NAME?
PLEASE INDICATE ID Number and Date of Issuance
Government Issued ID: Philhealth

ID/License/Passport No.: 052506766095

Signature (Sign inside the box)
September 14, 2022
Date/Place of Issuance: San Fernado City, La Union
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