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 BONDOC
NAME EXTENSION (JR., SR)
FIRST NAME KEITH RUZZEL

MIDDLE NAME QUIAMBAO

3. DATE OF BIRTH
(mm/dd/yyyy) 12/29/1997 16. CITIZENSHIP FILIPINO

4. PLACE OF BIRTH STO. TOMAS, PAMPANGA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX FEMALE

17. RESIDENTIAL ADDRESS 587 FERNANDINO STREET

6 CIVIL STATUS SINGLE
House/Block/Lot No. Street
SAN NICOLAS
Subdivision/Village Barangay
SAN FERNANDO PAMPANGA
7. HEIGHT (m) 1.6002
City/Municipality Province
8. WEIGHT (kg) 53.6 ZIP CODE 2000

18. PERMANENT ADDRESS 587 FERNANDINO STREET

9. BLOOD TYPE B+
House/Block/Lot No. Street
SAN NICOLAS
10. GSIS ID NO. -
Subdivision/Village Barangay
SAN FERNANDO PAMPANGA
11. PAG-IBIG ID NO. 1212-3647-6714
City/Municipality Province

12. PHILHEALTH NO. 0702-5945-6051 ZIP CODE 2000

13. SSS NO. 34-7305546-9 19. TELEPHONE NO. (045) 435-1368

14. TIN NO. 351-450-726-0000 20. MOBILE NO. (+63) 932 543 3213

15. AGENCY EMPLOYEE NO. - 21. E-MAIL ADDRESS (if any) KRBONDOC@GMAIL.COM

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

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME BONDOC

NAME EXTENSION (JR., SR)
FIRST NAME PAULITO
MIDDLE NAME YAMBAING
25. MOTHER'S MAIDEN NAME CAROL GOPEZ QUIAMBAO

SURNAME QUIAMBAO

FIRST NAME CAROL

MIDDLE NAME GOPEZ (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY UNIVERSITY OF THE ASSUMPTION 2004 2010 2010

Rank 7 for the A.Y.
2013-2014, Best in
SECONDARY /
VOCATIONAL ST. SCHOLASTICA’S ACADEMY 2010 2014 2014 Mathema tics IV
(A.Y.2013-2014)

TRADE Top 20 June 2018

COURSE
COLLEGE ANGELES UNIVERSITY FOUNDATION BS NURSING 2014 2018 2018 P hilippine Nur sing
Licensure Examination,
3rd P la ce in M ur al
P resentation in the 10th
National Nursing
Re sea rch C onfer ence,
GRADUATE STUDIES 3rd P la ce in Nursing
Quiz Be e 2017

(Continue on separate sheet if necessary)

SIGNATURE DATE
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 NURSING LICENSURE EXAM 83.4 JUNE 3-4, 2018 MANILA, PHILIPPINES 0907834 12/29/2021

C10-18-
DRIVER’S LICENSE - - LTO SAN FERNANDO, PAMPANGA 12/29/2022
007564

(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
SERVICE
28. INCLUSIVE DATES SALARY/ JOB/ PAY
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in full/Do (Write in SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) full/Do not abbreviate) INCREMENT
From To (Y/
N)

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 2 of 4

2
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
RETURNED AND SERVICES LEAGUE OF AUSTRALIA ANGELES CITY SUB
8/1/2015 8/1/2015 8h Barangay Children’s Medical Mission (Nurse)
BRANCH
RETURNED AND SERVICES LEAGUE OF AUSTRALIA ANGELES CITY SUB
7/2/2016 7/2/2016 8h Barangay Children’s Medical Mission (Nurse)
BRANCH
RETURNED AND SERVICES LEAGUE OF AUSTRALIA ANGELES CITY SUB
9/3/2016 9/3/2016 8h Barangay Children’s Medical Mission (Nurse)
BRANCH

(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) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To
Angeles University Foundation College of
Developing the Critical Thinking Skills of a Millenial Learner 8/16/2017 8/16/2017 5.0
Nursing Alumni Association
Discovering Career Opportunities: Home Health Nuring and Nurse Angeles University Foundation College of
11/29/2017 11/29/2017 5.0
Entrepreneurship Nursing Alumni Association
Angeles University Foundation Center for
Disaster Awareness and Preparedness Training 11/10/20`7 11/10/20`7 7.0
Christian Formation and Praxis

Basic First Aid 8/25/2017 8/25/2017 10.0 American Heart Association

Mass Casualty Incident 8/25/2017 8/25/2017 10.0 American Heart Association

Disaster Management with S.T.A.R.T. 8/25/2017 8/25/2017 10.0 American Heart Association

Basic Life Support for Healthcare Providers Course 8/24/2017 8/24/2017 10.0 American Heart Association

Seminar on Spirituality in the Healthcare Profession 3/17/2017 3/17/2017 10.0 American Heart Association

Angeles University Foundation Center for

Water Survival and Disaster Prevention Training 10/25/2016 10/25/2016 10.0
Christian Formation and Praxis

Seminar on Sex Education in Islamic Perspective 5/11/2016 5/11/2016 5.0 Angeles University Foundation

College of Nursing Leadership Seminar 08/15/2015 08/15/2015 10.0 Angeles University Foundation College of Nursing

(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
(Write in full)
in full)

Microsoft Office Literate Children of Mary Immaculate Member of the Year (2012-2013)

Children of Mary Immaculate Member of the Year (2013-2014)

(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?

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
3.5 cm. X 4.5 cm
Corazon, Tanhueco Angeles, Pampanga (045) 625-2888 (passport size)

With full and handwritten

Rhocette Sn Agustin Angeles, Pampanga (045) 625-2888 name tag and signature over
printed name
Jessie Nogoy Angeles, Pampanga (045) 625-2888 Computer generated
or photocopied picture
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and 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:

ID/License/Passport No.:
Signature (Sign inside the box)

Date/Place of Issuance:
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

4
Yes/No Cstat Gender
Yes Single Male
No Married Female
Separated
Widowed