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 ag
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

I. PERSONAL INFORMATION
2. SURNAME GUTIERREZ
NAME EXTENSION (JR., SR
FIRST NAME CHERRYL LOU

MIDDLE NAME PANIMBA

3. DATE OF BIRTH
(mm/dd/yyyy) 11/10/1982 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH DAUIN,NEGROS ORIENTAL If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male ✘ Female

Single ✘ Married 17. RESIDENTIAL ADDRESS

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. S
LI
Other/s:
Subdivision/Village Ba
DAUIN NEGRO
7. HEIGHT (m) 1.52
City/Municipality Pr
8. WEIGHT (kg) 56kg ZIP CODE

18. PERMANENT ADDRESS

9. BLOOD TYPE A+
House/Block/Lot No. S
LI
10. GSIS ID NO. 02004159516
Subdivision/Village Ba
DAUIN NEGRO
11. PAG-IBIG ID NO. 1210-2208-1291
City/Municipality Pr

12. PHILHEALTH NO. 12-000101473-6 ZIP CODE 6217

13. SSS NO. 0111-0831805-9 19. TELEPHONE NO. N/A

14. TIN NO. 405-993-806 20. MOBILE NO. 09753061176

15. AGENCY EMPLOYEE NO. IV-3 21. E-MAIL ADDRESS (if any) gutierrezcherryllou@yahoo.c
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME GUTIERREZ 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME MARLON BENCCI BERG P. GUTIERREZ

MIDDLE NAME ALEMAN BENEXXA BEE. P. GUTIERREZ

OCCUPATION PEDICAB DRIVER

EMPLOYER/BUSINESS NAME NONE

BUSINESS ADDRESS N/A

TELEPHONE NO. 9355621874

24. FATHER'S SURNAME PANIMBA

NAME EXTENSION (JR., SR)
FIRST NAME NASSER

MIDDLE NAME N/A

25. MOTHER'S MAIDEN NAME

SURNAME ALDEON

FIRST NAME BENIGNA

MIDDLE NAME N/A (Continue on separate sheet if necessary

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY DAUIN CENTRAL SCHOOL 1990 1996

SECONDARY DAUIN NATIONAL HIGH SCHOOL 1996 2000

VOCATIONAL /

N/A

TRADE
COURSE ST.PAUL COLLEGE DUMAGUETE CITY 2000 2003
COLLEGE
DIPOLOG MEDICAL CENTER COLLEGE
FOUDATION,INC.
2003 2005

GRADUATE STUDIES N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM
L DATA SHEET
erience Sheet shall cause the filing of administrative/criminal case/s against the person

EFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Dual Citizenship

by naturalization

Pls. indicate country:

Street
LIPAYO
Barangay
NEGROS ORIENTA
Province

Street
LIPAYO
Barangay
NEGROS ORIENTA
Province

6217

N/A

09753061176

gutierrezcherryllou@yahoo.com

DATE OF BIRTH (mm/dd/yyyy)

8/27/2007

12/24/2014

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

1996 1ST HONOR

MERIT
2000
AWARD
 SERVICE
AWARD

2005

parate sheet if necessary)

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 ap
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

BOARD OF NURSING 75% JUNE 5-6,2005 MANILA 0380817

(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.
28. INCLUSIVE DATES SALARY/ JOB/ PAY
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

3/16/2017 PRESENT BOOKKEEPER LGU DAUIN/TREASURER'S OFFICE 12,569.00 SG8 PERMANENT

2/16/2011 3/15/2017 ACCOUNTING CLERK I LGU DAUIN/ACCOUNTING OFFICE 7,152.00 SG4 PERMANENT

6/2006 01/2007 NURSE TRAINING NEGROS ORIENTAL PROVINCIAL HOSPITAL NONE N/A TRAINING

OSPITAL NG KABATAAN NG
10/11/2005 3/31/2006 STAFF NURSE RELIEVER 4,000.00 N/A RELIEVER
DIPOLOG,INC.
 (Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 20
 LICENSE (if applicable)

Date of
Validity

11/20121

eet if necessary)

GOV'T
SERVICE

(Y/
N)
Y

N
eet if necessary)

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 /
From To

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

BIZARRE DIMENSION: THE WORLD OF PSYCHIATRIC CARE NURSING 7/29/2019 7/29/2017 4 PHILIPPIN

FILIPINO NURSES: FOCUSING ON CAREER PATH DEVELOPMENT 6/17/2017 6/17/2017 8 PHILIPPIN

TRAINING ON THE USE OF THE ENHANCED FAMILY DEVELOPMENT DEVELOP

SESSION MANUAL
7/16/2012 7/20/2012 32 A

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERS
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

DAUIN
COOKING N/A
 DANCING PHILIPP

(Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

eparate sheet if necessary)

ROGRAMS ATTENDED
five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

PHILIPPINE NURSES ASSOCIATION,INC.

PHILIPPINE NURSES ASSOCIATION,INC.

DEVELOPMENT OF SOCIAL WELFARE

AND DEVELOPMENT

eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)
DAUIN MUNICIPAL EMPLOYEES
ASSOCIATION
 PHILIPPINE NURSES ASSOCIATION

eparate sheet if necessary)

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
YES ✘ NO
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, 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? Resignation due to new job opportunity
________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except YES ✘ NO
Barangay election)?
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
POB.DST.III,DAUIN NEGROS the last 6 months
HON.NEIL B. CREDO ORIENTAL
9177111108 3.5 cm. X 4.5 cm
(passport size)
MASAPLOD SUR,DAUIN NEGROS
LILIBETH G. SALATAN ORIENTAL
9262655836 With full and handwritten
name tag and signature over
POB.DST.II,DAUIN NEGROS printed name
MARIA ANA E. DELFINO ORIENTAL
9177002015
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
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: PRC

ID/License/Passport No.: 0380817

Signature (Sign inside the box)

Date/Place of Issuance: 11/14/2017-DUMAGUETE 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 o

 If YES, give details (country):

, affiant exhibiting his/her validly issued government ID as indicated above.

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