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 VARGAS
NAME EXTENSION (JR., SR)
FIRST NAME JOGIELYN

MIDDLE NAME LABORADA

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
12/14/1989 by by
birth naturalization
4. PLACE OF BIRTH KABASALAN, ZAMBOANGA DEL SUR If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS

House/Block/Lot No. Street
Separat
Widowed SAN VICENTE
Other/s: ed Subdivision/Village Barangay
TUBAJON DINAGAT ISLANDS
7. HEIGHT (cms) 159 cms
City/Municipality Province
8. WEIGHT (kg) 98 kgs ZIP CODE

18. PERMANENT ADDRESS

9. BLOOD TYPE B+
House/Block/Lot No. Street
SAN VICENTE
10. GSIS ID NO. none
Subdivision/Village Barangay
TUBAJON DINAGAT ISLANDS
11. PAG-IBIG ID NO. none
City/Municipality Province

12. PHILHEALTH NO. 18-025166911-0 ZIP CODE

13. SSS NO. 0826257529 19. TELEPHONE NO.

14. TIN NO. 415-071-335 20. MOBILE NO.

15. AGENCY EMPLOYEE NO. none 21. E-MAIL ADDRESS (if any)

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 JORGE JEROH VARGAS VITOR 6/8/2013

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME VARGAS

FIRST NAME GEORGE SR.

MIDDLE NAME LABICANE

25. MOTHER'S MAIDEN NAME CERNA

SURNAME VARGAS
FIRST NAME JOSEFINA
MIDDLE NAME LABORADA (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 GRADUATED ACADEMIC
LEVEL (Write in EARNED HONORS
(Write in full)
full) (if not graduated) RECEIVED
From To
TUBAJON CENTRAL ELEMENTARY SALUTATORI
ELEMENTARY 1996 2002 GRADUATED 2002
SCHOOL AN

SALUTATO
SECONDARY /
VOCATIONAL TUBAJON NATIONAL HIGH SCHOOL 2003 2006 GRADUATED 2006
RIAN

TRADE
BACHELOR OF SCIENCE IN
COURSE
COLLEGE SURIGAO EDUCATION CENTER 2006 2010 GRADUATED 2010 NONE
NURSING

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE January 7, 2020

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
CAPITOL UNIVERSITY, CAGAYAN DE ORO
NURSING LICENSURE EXAMINATION 75% 11/18/2011 0730957 12/14/2021
CITY

(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 not (Write in SALARY
applicable)& STEP
APPOINTMENT
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To (Y/
N)
DEPARTMENT OF HEALTH, CENTER FOR HEALTH CONTRACT OF
7/1/2019 12/31/2019 PUBLIC HEALTH ASSOCIATE DEVELOPMENT REGION XIII
32, 057.55 SG-15 SERVICE N
DEPARTMENT OF HEALTH, CENTER FOR HEALTH CONTRACT OF
1/23/2014 12/31/2018 NURSE DEPLOYMENT PROJECT DEVELOPMENT REGION XIII
31,765 SG-15 SERVICE N

(Continue on separate sheet if necessary)

SIGNATURE DATE January 7, 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

PHILIPPINE NURSES ASSOCIATION 2011 PRESENT MEMBER

NATIONAL LEAGUE OF PHILIPPINE GOVERNMENT NURSES

2011 PRESENT MEMBER
INCORPORATED

(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

PHILIPPINE NURSES ASSOCIATION NATIONAL CONVENTION 2018 11/8/2018 11/11/2018 32 HOURS TECHNICAL PHILIPPINE NURSES ASSOCIATION

HEALTHY YOUNG ONES WITH ADEPT TRAINING 10/10/2018 10/12/2018 24 HOURS TECHNICAL
DEPARTMENT OF HEALTH

ORIENTATION ON GENDER SENSITIVITY FOR HEALTH SERVICE PROVIDERS 9/12/2018 9/14/2018 24 HOURS TECHNICAL
DEPARTMENT OF HEALTH

HRH ENGAGEMENT ON BHLMP IN ATTAINING FORMULA ONE PLUS 10/22/2018 10/23/2018 16 HOURS TECHNICAL
DEPARTMENT OF HEALTH

FAMILY PLANNING COMPETENCY-BASED TRAINING- LEVEL 1 9/12/2017 9/16/2017 40 HOURS TECHNICAL

DEPARTMENT OF HEALTH

(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)
PHILIPPINE WOMEN'S ASSOCIATION
COMPUTER LITERATE
(TUBAJON CHAPTER)
TUBAJON PHYSICAL THERAPIST
VOLLEYBALL PLAYER
ORGANIZATION

(Continue on separate sheet if necessary)

SIGNATURE DATE January 7, 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
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? ________________________________
________________________________
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 CELLPHONE NO.

ID picture taken within
DR. KARLA CARISE J. VINLUAN (FORMER DTTB/MHO the last 6 months
DAVAO CITY 0908-8198-389 3.5 cm. X 4.5 cm
OF RHU TUBAJON) (passport size)
SAN ROQUE, TUBAJON, DINAGAT
FLORIDA O. TOROTORO, RN (DMO-IV) ISLANDS
0946-9155-054 With full and handwritten
name tag and signature over
printed name
SHEBA B. ESTOBO, RN (PHN OF RHU LIBJO) ALBOR, LIBJO, DINAGAT ISLANDS 0912-6893-874
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 PROFESSIONAL ID

ID/License/Passport No.: 0730957

Signature (Sign inside the box)
January 7, 2020
Date/Place of Issuance: 11/18/2011
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