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 only)
I. PERSONAL INFORMATION
2. SURNAME GUIYAB
NAME EXTENSION (JR., SR) N/A
FIRST NAME CORAZON

MIDDLE NAME CABAUATAN

3. DATE OF BIRTH
(mm/dd/yyyy) 10/22/1957 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH STA.MARIA,ISABELA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS BLOCK16/Lot17 MT.ISAROG RD.
Widowed Separate House/Block/Lot No. Street
d MONTE VISTA HEIGHT DOLORES
Other/s:
Subdivision/Village Barangay
TAYTAY RIZAL
7. HEIGHT (m) 1.55m
City/Municipality Province
8. WEIGHT (kg) 50.kg ZIP CODE 790

18. PERMANENT ADDRESS BLOCK16/Lot17 MT.ISAROG RD.

9. BLOOD TYPE ''O+''
House/Block/Lot No. Street

10. GSIS ID NO. CRN-006-0018-3954-6 MONTE VISTA HEIGHT DOLORES

TAYTAY RIZAL
11. PAG-IBIG ID NO.
City/Municipality Province

12. PHILHEALTH NO. ZIP CODE 790

13. SSS NO. n/a 19. TELEPHONE NO. n/a

14. TIN NO. 109-858-847 20. MOBILE NO. 09276447937

15. AGENCY EMPLOYEE NO. 425 21. E-MAIL ADDRESS (if any)

II. FAMILY BACKGROUND

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

MIDDLE NAME

OCCUPATION n/a

EMPLOYER/BUSINESS NAME n/a

BUSINESS ADDRESS n/a

TELEPHONE NO.

24. FATHER'S SURNAME GUIYAB

NAME EXTENSION (JR., SR)
FIRST NAME CARLOS

MIDDLE NAME GERAY

25. MOTHER'S MAIDEN NAME

SURNAME CABAUATAN

FIRST NAME ELVIRA

MIDDLE NAME GUZMAN (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY STA.MARIA ELEMENTARY SCHOOL PRIMARY 1964 1970 1970

SECONDARY STA.MARIA COMMUNITY HIGH SCHOOL HIGH SCHOOL 1970 1974 1974

VOCATIONAL / TRADE n/a

COURSE

COLLEGE UNIVERSITY OF THE EAST BSBA 1975 1979

GRADUATE STUDIES n/a

(Continue on separate sheet if necessary)

SIGNATURE DATE January 30, 2020

CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY
27. LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER RATING DATE OF
SPECIAL LAWS/ CES/ CSEE (If Applicable) EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT NUMBER Date of
Validity

Career Service Sub-Professional 70.84% MAY 1984 MANDALUYONG CITY n/a 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
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY GRADE (if STATUS OF
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To (Y/ N)

02/01/2019 PRESENT Nursing Attendant II Philippine Heart Center P15,545. 06 - Permanent Yes

01/01/2018 1/31/2019 Nursing Attendant II Philippine Heart Center P15,066. 06 - Permanent Yes

02/01/2017 12/31/2018 Nursing Attendant II Philippine Heart Center P14,474. 06 - Permanent Yes

03/01/2016 1/31/2017 Nursing Attendant II Philippine Heart Center P14,020. 06 - Permanent Yes

06/02/2013 2/28/2016 Nursing Attendant II Philippine Heart Center P13,312. 06 - Permanent Yes

08/03/2005 06/01/2013 Nursing Attendant II Philippine Heart Center P12,426. 06 - Permanent Yes

08/03/2002 08/08/2005 Nursing Attendant II Philippine Heart Center P7,796. 06 - Permanent Yes

07/01/2001 08/02/2002 Nursing Attendant II Philippine Heart Center P7,606. 06 - Permanent Yes

01/01/2000 06/30/2001 Nursing Attendant II Philippine Heart Center P7,244. 06 - Permanent Yes

08/03/1999 12/31/1999 Nursing Attendant II Philippine Heart Center P6585. 06 - Permanent Yes

11/19/1998 08/02/1999 Nursing Attendant Philippine Heart Center P5,646. 06 - Casual Yes

11/19/1997 11/18/1998 Nursing Attendant Philippine Heart Center P5,646. 06 - Casual Yes

(Continue on separate sheet if necessary)

SIGNATURE DATE January 30, 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

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

PAG-IBIG MP1 FOR RETIRING EMPLOYEES 2/21/2019 020/21/2019 4hours Phillipine Heart Center

WELLNESS LEARNING SESSION MIND AND CHARACTER 6/21/2019 6/21/2019 3hours Phillipine Heart Center

INFECTION PREVENTION AND CONTROL IN EVERY SEASON 10/24/2019 10/24/2019 8hours Phillipine Heart Center

WOES OF WOMEN:FACING THE REALITY 5/4/2017 5/4/2017 3hours Phillipine Heart Center

A REFLECTIONS ON THE MOVIE GODS NOT DEAD 4/5/2017 4/5/2017 3hours Phillipine Heart Center

WOMEN AND THE ENVIRONMENT:TOXIC FREE FUTURE 3/31/2017 3/31/2017 3hours Phillipine Heart Center

ANG KABABAIHAN NG MALOLOS 3/30/2017 3/30/2017 3hours Phillipine Heart Center

GENDER SENSITIVE BEAUTY BEYOND BONES 3/9/2017 3/9/2017 5hours Phillipine Heart Center

RULES ON ADMINISTRATIVE CASES and PENALTIES 11/17/2016 11/17/2016 4hours Phillipine Heart Center

MONEY MARKET FUND and FINANCIAL INVESTMENT 11/11/2016 11/11/2016 2hours Phillipine Heart Center

RULES ON ADMINISTRATIVE CASES and PENALTIES 09/21/2016 09/21/2016 4hours Phillipine Heart Center

COOPERATIVE MANAGEMENT and GOVERNANCE 08/10/2016 08/11/2016 16hours Phillipine Heart Center

Nurturing Understanding Respect And Sosial Responsibility in the Ngeneration of 08/05/2016 08/05/2016 8hours Phillipine Heart Center
Employees

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. NON-ACADEMIC DISTINCTIONS / RECOGNITION (Write in full) 33. (Write in
full)

COOKING 30 YEARS SERVICE AWARDEE 2016 Nursing Service Employee of the Phillipine
Heart Center
Phillipine Heart Center Employees Association
BAKING 25 YEARS SERVICE AWARDEE 2011 Alliance of Health Workers

GARDENING 20 YEARS SERVICE AWARDEE 2006 Phillipine Heart Center Development Cooperative

15 YEARS SERVICE AWARDEE 2001

10 YEARS SERVICE AWARDEE 1996

5 YEARS SERVICE AWARDEE 1991

(Continue on separate sheet if necessary)

SIGNATURE DATE January 30, 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 ✘

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
by any court or tribunal? YES ✘ NO
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
Barangay election)? YES ✘ NO
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
DERIS,EMERSON Philippine Heart Center,Q.C. 925-2401 3.5 cm. X 4.5 cm
(passport size)

CRUZ,ANACLETA Philippine Heart Center,Q.C. 925-2401 With full and handwritten

name tag and signature over
printed name
PANAGUITON,DIONITA Philippine Heart Center,Q.C. 925-2401
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
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable
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
administrative/criminal case/s against me. PHOTO

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of
Issuance
Government Issued ID: GSIS

ID/License/Passport No.: UMID-CRN-006-0018-3954-6

Signature (Sign inside the box)
01-30-2020
Date/Place of Issuance: 2010/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