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 SSPALIMA
NAME EXTENSION (JR., SR) N/A
FIRST NAME SSMA. HAZEL

MIDDLE NAME SSMIRABALLES

3. DATE OF BIRTH
(mm/dd/yyyy) 12/22/2002 16. CITIZENSHIP
✘

4. PLACE OF BIRTH DONSOL, SORSOGON If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘

6 CIVIL STATUS ✘ 17. RESIDENTIAL ADDRESS N/A SITIO PINARIK

House/Block/Lot No. Street
N/A OGOD
Subdivision/Village Barangay

7. HEIGHT (m) 1.44m DONSOL SORSOGON

City/Municipality Province
8. WEIGHT (kg) 41kg ZIP CODE HHHHHHHHHHHHHHHHHH4715

9. BLOOD TYPE B+ 18. PERMANENT ADDRESS N/A SITIO PINARIK

House/Block/Lot No. Street

10. GSIS ID NO. N/A N/A OGOD

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121356436035 DONSOL SORSOGON

City/Municipality Province

12. PHILHEALTH NO. 10-254632543-9 ZIP CODE HHHHHHHHHHHHHHHHHH4715

13. SSS NO. 05-1864713-3 19. TELEPHONE NO. HHHHHHHHHHHHHHHHHHHHHHHHHN/A

14. TIN NO. 669369269 20. MOBILE NO. 09638772915LLLLLLLLLLL

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

FIRST NAME SSN/A NAME EXTENSION (JR., SR) N/A N/A

N/A
MIDDLE NAME SSN/A N/A N/A

OCCUPATION SSN/A N/A N/A

EMPLOYER/BUSINESS NAME SSN/A N/A N/A

BUSINESS ADDRESS SSN/A N/A N/A

TELEPHONE NO. SSN/A N/A N/A

24. FATHER'S SURNAME DJPALIMA N/A N/A

FIRST NAME SSRODEL NAME EXTENSION (JR., SR) N/A N/A

N/A
MIDDLE NAME SSVILLAR N/A N/A

25. MOTHER'S MAIDEN NAME

N/A N/A

SURNAME JJJMIRABALLES N/A N/A

FIRST NAME NNMARICEL N/A N/A

MIDDLE NAME HHLONOSA

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

ELEMENTARY OGOD ELEMENTARY SCHOOL PRIMARY EDUCATION 2008P 2014T GRADUATED 2014H WITH
HONOR

SECONDARY
DONSOL NATTIONAL COMPREHENSIVE SENIOR HIGH SCHOOL GRADUATE 2014T 2020P GRADUATED 2020P WITH HIGH
VOCATIONAL / HIGH SCHOOL HONOR

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

TRADE 3RD PLACE IN
COURSE NURSING
COLLEGE BICOL UNIVERSITY - POLANGUI BACHELOR OF SCIENCE IN NURSING 2020I 2024T GRADUATED 2024 DEPARTMENT MOCK
BOARD
EXAMINATION

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

(Continue on separate sheet if necessary)

SIGNATURE DATE March 14, 2025

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
PHILIPPINE NURSES LICENSURE EXAMINATION W288.20 NOVEMBER 9-10,
LEGAZPI CITY N/A N/A
BOARD PASSER 2024

N/A N/A N/A N/A HHHN/A N/A

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

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

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

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

N/A N/A N/A N/A 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)

01/23/2025 04/23/2025 STAFF NURSE SORSOGON MEDICAL MISSION GROUP 16000.00 N/A CONTRACTUAL NO
HOSPITAL AND HEALTH SERVICES
N/A N/A N/A N/A N/A N/A N/A N/A

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

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

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

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

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

(Continue on separate sheet if necessary)

SIGNATURE DATE MARCH 14, 2025

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

PHIILIPPINE NURSING STUDENTS ASSOCIATION - BICOL UNIVERSITY POLANGUI 2020J 2021W N/A AUDITOR

COMMUNITY HEALTH ACTION HEALTH VOLUNTEERS - BICOL UNIVERSITY 2020J 2024T N/A MEMBER
POLANGUI

RED CROSS YOUTH COUNCIL - BICOL UNIVERSITY POLANGUI 2022D 2024T N/A MEMBER

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

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

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

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
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
SORSOGON MEDICAL MISSION GROUP
BASIC LIFE SUPPORT TRAINING 03/20/2025 03/20/2025 10 HOURS TECHNICAL HOSPITAL AND HEALTH SERVICES
COOPERATIVE
N/A N/A N/A N/A N/A
N/A
N/A N/A N/A N/A N/A
N/A
N/A N/A N/A N/A N/A
N/A
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N/A
N/A N/A N/A N/A N/A
N/A
N/A N/A N/A N/A N/A SSSSSSSN/A

N/A N/A N/A N/A N/A SSSSSSSN/A

N/A N/A N/A N/A N/A SSSSSSSN/A

SSSSSSSSSSSSSSSSSSSSSSN/A N/A N/A N/A N/A

N/AXXXXXXXXXXXXXXXXXXXXX
SSSSSSSSSSSSSSSSSSSSSSN/A N/A N/A N/A N/A
N/A
SSSSSSSSSSSSSSSSSSSSSSN/A N/A N/A N/A N/A
N/A
SSSSSSSSSSSSSSSSSSSSSSN/A N/A N/A N/A N/A
N/A
SSSSSSSSSSSSSSSSSSSSSSN/A N/A N/A N/A N/A
N/A
SSSSSSSSSSSSSSSSSSSSSSN/A N/A N/A N/A N/A
N/A
N/A N/A N/A N/A N/A SSSSSSSN/A

N/A N/A N/A N/A N/A SSSSSSSN/A

N/A N/A N/A N/A N/A SSSSSSSN/A

N/A N/A N/A N/A N/A SSSSSSSN/A

(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)

CPR AND BASIC LIFE SUPPORT N/A PHILIPPINE NURSES ASSOCIATION

CRITICAL THINKING AND PROBLEM SOLVING N/A N/A

FLEXIBILITY AND ADAPTABILITY N/A N/A

EMPATHY N/A N/A

TEAMWORK AND COLLABORATION N/A N/A

TIME MANAGEMENT N/A N/A

CLINICAL SKILLS AND PATIENT CARE N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE MARCH 14, 2025

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.

ID picture taken within
the last 6 months
MARVIN R. VELACRUZ, RN, MAN POLANGUI, ALBAY 09776321478 4.5 cm. X 3.5 cm
(passport size)
MARIA BRENDA P. YACHIONGCO, RN, MAN GUINOBATAN, ALBAY 09173073393
Computer generated
or photocopied picture
RONALD L. LOMERIO, LPT DONSOL, SORSOGON 09206422839 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: PHILHEALTH ID

ID/License/Passport No.: 10-254632543-9

Signature (Sign inside the box)
03/14/2025
Date/Place of Issuance: LEGAZPI 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