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 RUBINOS
NAME EXTENSION (JR., SR)
FIRST NAME MITCH

MIDDLE NAME BONTIA JR.

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 2/22/1999 ✘ Filipino Dualby Citizenship
✘ birt
by
naturalization
h
4. PLACE OF BIRTH QUEZON CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS BLK 20 LOT 15 PHASE III
Widow Separat House/Block/Lot No. Street
ed ed DELA COSTA HOMES III GRACEVILLE
Other/
Subdivision/Village Barangay
s:
SAN JOSE DEL MONTE BULACAN
7. HEIGHT (m) 1.65
City/Municipality Province
8. WEIGHT (kg) 69 ZIP CODE 3023

18. PERMANENT ADDRESS BLK 20 LOT 15 PHASE III

9. BLOOD TYPE A+
House/Block/Lot No. Street
DELA COSTA HOMES III GRACEVILLE
10. GSIS ID NO. 2005791315
Subdivision/Village Barangay
SAN JOSE DEL MONTE BULACAN
11. PAG-IBIG ID NO. 1212-7273-1453
City/Municipality Province

12. PHILHEALTH NO. 03-251545479-8 ZIP CODE 3023

13. SSS NO. N/A 19. TELEPHONE NO. N/A

14. TIN NO. 712-133-044-000 20. MOBILE NO. 09958455411

15. AGENCY EMPLOYEE NO. 8351 21. E-MAIL ADDRESS (if any) rubinosmitchb@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME N/A N/A N/A

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N

24. FATHER'S SURNAME RUBINOS

NAME EXTENSION (JR., SR)
FIRST NAME ARNULFO

MIDDLE NAME GAINTANO N/A

25. MOTHER'S MAIDEN NAME

SURNAME BONTIA

FIRST NAME MELANIA

MIDDLE NAME YBAÑEZ (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY DOÑA ROSARIO ELEMENTARY SCHOOL ELEMENTARY 6/1/2006 3/25/2011 N/A 2011 N/A

SECONDARY DOÑA ROSARIO HIGH SCHOOL HIGH SCHOOL 6/5/2011 3/28/2015 N/A 2015 N/A
VOCATIONAL /

LA CONCEPCION COLLEGE CERTIFICATE IN TEACHING PROFESSION 8/5/2022 12/28/2022 18 UNITS 2022 N/A
TRADE
COURSE
COLLEGE NEW ERA UNIVERSITY BACHELOR OF PUBLIC ADMINISTRATION 7/1/2015 4/16/2019 N/A N/A SERVICE
AWARDEE

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)
SIGNATURE DATE
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
LICENSURE EXAMINATION FOR PROFESSIONAL 78.6 09/24/20203 MANILA CITY 2177849 2/22/2017
TEACHER

CAREER SERVICE-SUB PROFESSIONAL LEVEL 80.8 3/23/2023 MANILA CITY 932603 N/A

NON-PROFESSIONAL DRIVER'S LICENSE N/A N/A QUEZON CITY N25-21-002368 02/22/2025

(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)
HEALTH INFORMATION MANAGEMENT
6/1/2021 PRESENT ADMINISTRATIVE AIDE I DEPARTMENT/ EAST AVENUE MEDICAL 19,500 PHP SG-1 Regular Y
CENTER
8/11/2020 5/25/2021 ADMINISTRATIVE AIDE I BILLING AND PHILHEALTH CLAIMS UNIT/ 18500.00 SG-1 Regular Y
EAST AVENUE MEDICAL CENTER
CHIEF OF MEDICAL PROFESSIONAL SERVICES/
5/4/2020 7/31/2020 ADMINISTRATIVE ASSISTANT II EAST AVENUE MEDICAL CENTER 21,500 PHP SG-8 CONTRACTUAL Y
HEALTH INFORMATION MANAGEMENT
7/5/2019 3/15/2020 ADMINISTRATIVE AIDE I DEPARTMENT/ EAST AVENUE MEDICAL 10,500 PHP SG-1 CONTRACTUAL Y
CENTER

(Continue on separate sheet if necessary)

SIGNATURE DATE
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 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
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
ONLINE RE-ORIENTATION ON MEDICAL CERTIFICATION OF CAUSE OF DEATH (MCCOD) 4/25/2023 4/25/2023 4 OTHERS CISCO WEBEX ONLINE PLATFORM
ASSESSMENT
TRAINING COURSE ON THE INTERNATIONAL CLASSIFICATION OF DISEASE VERSION 10 8/1/2022 8/12/2022 40 TECHNICAL DEPARTMENT OF HEALTH
(ICD-10) FOR CODERS

THE FUTURES OF PHILIPPINE SERVICE SYSTEM 2023 4/5/2022 4/5/2022 4 OTHERS UP NCPAG FUTURE LABS AND DEVELOPMENT
ACADEMY OF THE PHILIPPINES

CONFERENCE ON PUBLIC SECTOR PRODUCTIVITY 8/25/2024 8/25/2021 4 OTHERS DEVELOPMENT ACADEMY OF THE PHILIPPINES

THE PHILIPPINE ICTEX INNOVATION 7/28/2021 7/30/2024 4 OTHERS MYKAR EVENTS CONSULTANCY

AWARENESS SEMINAR ON DATA PRIVACY ACT ON THE HEALTH SECTOR 8/7/2019 8/7/2019 4 OTHERS NATIONAL PRIVACY COMMISSION

(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)

Driving N/A N/A

- NOTHING FOLLOWS -

(Continue on separate sheet if necessary)

SIGNATURE DATE
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:

________________________________
N/A

35. a. Have you ever been found guilty of any administrative offense? ✘ NO
YES
If YES, give details:
________________________________
N/A
________________________________

b. Have you been criminally charged before any court? ✘ NO

YES
If YES, give details:
________________________________
Date Filed:
________________________________ N/A
Status of Case/s: N/A
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:
________________________________
N/A
________________________________
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 YES ✘ NO
out (abolition) in the public or private sector? If YES, give details:
________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? ✘ NO
YES
If YES, give details: N/A
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: N/A
39. Have you acquired the status of an immigrant or permanent resident of another country?
✘ NO
YES
If YES, give details (country):
N/A
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? ✘ NO
If YES,YES
please specify: N/A
b. Are you a person with disability? ✘ NO
If YES,YES
please specify ID No: N/A
c. Are you a solo parent? ✘ NO
If YES,YES
please specify ID No: N/A

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

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
ALICIA P. NUNAG EAST AVENUE, DILIMAN, QUEZON CITY 928-0611 4.5 cm. X 3.5 cm
(passport size)
ATTY. RONNIE RAGONTON EAST AVENUE, DILIMAN, QUEZON CITY 928-0611
Computer generated
AGHAM CORNER Q. AVENUE, QUEZON or photocopied picture
MA. CATHERINA BENEDICTOS, MPA CITY 85889900 is not acceptable

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
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: PRC

ID/License/Passport No.: 2177849

Signature (Sign inside the box)

Date/Place of Issuance: LUCKY CHINA TOWN, MANILA

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