Print legibly if accomplished through own handwriting. Tick appropriate boxes and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE. 1.
2. ELCID
NICOLAS
3.
16. CITIZENSHIP
4. PLACE OF BIRTH
5. SEX AT BIRTH
17. RESIDENTIAL ADDRESS
8.
18. PERMANENT ADDRESS
12. PHILHEALTH NO.
13. PhilSys Number (PSN): 19. TELEPHONE NO.
20. MOBILE NO.
15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME
FIRST NAME
MIDDLE NAME
OCCUPATION
EMPLOYER/BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.
24. FATHER'S SURNAME
FIRST NAME
MIDDLE NAME
25.
SURNAME
FIRST NAME
MIDDLE NAME
III. EDUCATIONAL BACKGROUND
From To
ELEMENTARY 1972 1978 GRADUATED 1978 N/A
SECONDARY 1978 1982 GRADUATED 1982 N/A
VOCATIONAL /
TRADE COURSE
N/A N/A N/A N/A N/A
COLLEGE 1982 1987 GRADUATED 1987 N/A
GRADUATE STUDIES N/A N/A N/A N/A N/A
15 SEPTEMBER 1964
MARIKINA CITY NATIONAL CAPITAL REGION
1800
BACHELOR OF SCIENCE IN BUSINESS
ADMINISTRATION - Major in Accounting
MENDOZA (Continue on separate sheet if necessary)
PERIOD OF ATTENDANCE
MOTHER'S MAIDEN NAME
N/A
N/A
N/A
N/A
N/A
N/A
READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM. Street
STO. NIÑO
Subdivision/Village
10.
11.
O+
416*-****-**** 0880
6
7.
CIVIL STATUS
DATE OF BIRTH
(dd/mm/yyyy)
NAME EXTENSION (JR., SR) N/A
please indicate the details.
If holder of dual citizenship,
9.
HEIGHT (m)
WEIGHT (kg)
BLOOD TYPE
Pls. indicate country:
J. P. RIZAL STREET
85 KG.
House/Block/Lot No. Street
Subdivision/Village Barangay
House/Block/Lot No.
546
1800
MANILA
287*-****-**** 8532
546
***************@*****.***
N/A
172 CM
03-000237251-3
UMID ID NO.
PAG-IBIG ID NO.
PERSONAL DATA SHEET
I. PERSONAL INFORMATION
SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED
DATE OF BIRTH (dd/mm/yyyy)
26. YEAR
GRADUATED
MENDIOLA
1444
SURNAME
FIRST NAME
MIDDLE NAME
ZIP CODE
NAME EXTENSION (JR., SR) N/A
14. TIN NO. 115 392 750
N/A
N/A
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.
N/A
LEVEL
NAME OF SCHOOL
(Write in full)
ROOSEVELT COLLEGE
ROOSEVELT COLLEGE
N/A
PHILIPPINE SCHOOL OF BUSINESS
ADMINISTRATION
N/A
Barangay
MARIKINA CITY NATIONAL CAPITAL REGION
City/Municipality Province
City/Municipality Province
J. P. RIZAL STREET
ZIP CODE
N/A
STO. NIÑO
23. NAME of CHILDREN (Write full name and list all) CS FORM 212 (Revised 2025), Page 1 of 4
SIGNATURE
(Continue on separate sheet if necessary)
05/28/2026
RODOLFO
YUMENA
DATE
HIGHEST LEVEL/
UNITS EARNED
(if not graduated)
ELEMENTARY
MENDIOLA
NICOLAS
VIOLETA
NAME EXTENSION (JR., SR)
N/A
BASIC EDUCATION/DEGREE/COURSE
(Write in full)
HIGH SCHOOL
N/A
CS Form No. 212
Revised 2025
Filipino Dual Citizenship
Male Female
Single Married
Widowed
Other/s:
Separated
by birth by naturalization
27.
NUMBER Valid Until
80.18 QUEZON CITY N/A N/A
(Include private employment. Start from your recent work.) Description of duties should be indicated in the attached Work Experience Sheet. 28.
To
Present PERMANENT Y
01/01/2023 31/05/2023 CONTRACTUAL N
31/12/2022 CONTRACTUAL N
11/06/2020 PERMANENT N
15/12/2019 PERMANENT N
30/07/2019 PERMANENT N
05/01/2019 PERMANENT N
05/04/2018 PERMANENT N
28/12/2013 PERMANENT N
15/07/2012 PERMANENT N
15/10/2011 PERMANENT N
31/07/2010 CONTRACTUAL Y
15/01/2008 CONTRACTUAL N
15/01/2008 CONTRACTUAL N
30/05/2007 CONTRACTUAL N
15/08/2006 PERMANENT N
15/02/2004 CONTRACTUAL N
15/09/2002 CONTRACTUAL N
15/11/2001 PERMANENT N
15/12/2000 PERMANENT N
31/12/1990 PERMANENT N
31/08/1988 CONTRACTUAL N
DATE
01/07/2020
10/03/2020
PRODUCTION OPERATOR DECO AUTOMOTIVES - CANADA
01/03/2007 ORDER PICKER/CHECKER
THE GREAT ATLANTIC AND PACIFIC CORPORATION -
CANADA
10/08/2012
01/05/2007
16/02/2004
05/09/2010
01/05/2007
06/04/2018
ACCOUNTING/HR OFFICER
PAYROLL DATA ENCODER
STORE MANAGER / BAR TENDER BOWLERAMA - CANADA
04/11/1988 DEPARTMENT OF PUBLIC WORKS AND HIGHWAYS PROWATER TECHNOLOGIES INC.
16/03/2002 PRODUCTION OPERATOR BEST MADE TOYS - CANADA TRADERS ROYAL BANK
01/05/2003
BRANCH ACCOUNTANT
BOOKKEEPER/DISTRIBUTING/CLEARING
ZEN MANPOWER CORP.
GENERAL ACCOUNTANT
RIVERSTAR FOOD CORP.
JNE TOP MANPOWER
PAYROLL SPECIALIST
FAST FRESH FOOD - CANADA
PAYROLL OFFICER
GOVERNMENT OF MARIKINA CITY
PRODUCTION OPERATOR HCR - CANADA
TRADERS ROYAL BANK
16/08/2008
CS FORM 212 (Revised 2025), Page 2 of 4
02/01/1989 BANK CLERK TRADERS ROYAL BANK
16/12/2000
02/01/1991
SIGNATURE
PAYROLL CLERK / SUPPLY CHECKER
STORE MANAGER
(Continue on separate sheet if necessary)
5/28/2026
AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER
INCLUSIVE DATES
(dd/mm/yyy)
01/06/2023
(Continue on separate sheet if necessary)
V. WORK EXPERIENCE
ADMINSTRATIVE ASSISTANT II
PROJECT SPECIALIST THE SERENDIPITY GROUP
25/07/2019
02/01/2014
05/04/2019
02/06/2012
ADMINISTRATIVE AIDE IV AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER ADMINSTRATIVE ASSISTANT II AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER PYO INTERNATIONAL CORPORATION
HR MANAGER
HUMAN RESOURCES MANAGER PYO INTERNATIONAL CORPORATION 24/7 INTHOUCH
STATUS OF
APPOINTMENT
HUMAN RESOURCES MANAGER
CES/CSEE/CAREER SERVICE/RA 1080 (BOARD/
BAR)/UNDER SPECIAL LAWS/CATEGORY II/ IV ELIGIBILITY and ELIGIBILITIES FOR UNIFORMED PERSONNEL
DATE OF
EXAMINATION /
CONFERMENT
PLACE OF EXAMINATION /
CONFERMENT
LICENSE (if applicable)
RATING
(If Applicable)
IV. CIVIL SERVICE ELIGIBILITY
GOV'T SERVICE
(Y/ N)
From
POSITION TITLE
(Write in full/Do not abbreviate)
CIVIL SERVICE ELIGIBILITY - PROFESSIONAL NOV. 2008 DEPARTMENT / AGENCY / OFFICE / COMPANY
(Write in full/Do not abbreviate)
From To
N/A N/A N/A
From To
26/05/2026 26/05/22026 4 HOURS TECHNICAL
07/07/2025 07/07/2025 8 HOURS TECHNICAL
24/01/2024 24/01/2024 4 HOURS TECHNICAL
06/12/2023 07/12/2023 16 HOURS TECHNICAL
CIVIL SERVICE COMMISSION
04/12/2024 04/12/2024 4 HOURS TECHNICAL
04/04/2023 04/04/2023 5 HOURS TECHNICAL
23/06/2022 23/06/2022 2 HOURS TECHNICAL
14/12/2021 14/12/2021 4 HOURS
TECHNICAL
17/06/2021 17/06/2021 4 HOURS
TECHNICAL
28/10/2014 28/10/2014 4 HOURS MANAGERIAL
28/10/2014 28/10/2014 4 HOURS MANAGERIAL
21/10/2014 21/10/2014 4 HOURS MANAGERIAL
09/12/2010 09/12/2010 8 HOURS TECHNICAL
25/03/2009 27/03/2009 24 HOURS TECHNICAL
18/03/2009 19/03/2009 8 HOURS SUPERVISORY
31. SPECIAL SKILLS and HOBBIES 32. 33.
CS FORM 212 (Revised 2025), Page 3 of 4
POLICIES AND PROCEDURES ON APPOINTMENT
IMPROVING AND MEASURING QUALITY SERVICE FOR PUBLIC SERVANTS GOVERNMENT OF MARIKINA CITY AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER
PAG-IBIG - CUBAO BRANCH
AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER
AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER
INTEGRA PAYROLL SYSTEM -HRIS SECURITY BANK
TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS
(Write in full)
Type of L&D
( Managerial/
Supervisory/
Technical/etc)
29. NAME & ADDRESS OF ORGANIZATION
(Write in full)
N/A
(Continue on separate sheet if necessary)
POSITION / NATURE OF WORK
INCLUSIVE DATES
(dd/mm/yyyy)
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S CONDUCTED/ SPONSORED BY
(Write in full)
INCLUSIVE DATES OF
ATTENDANCE
(dd/mm/yyyy)
NUMBER OF HOURS
N/A
30.
SIGNATURE
ADVOCACY LECTURE ABOUT ORGAN DONATION
AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER
DEPARTMENT OF LABOR AND EMPLOYMENT
BEYOND COVID-19 VACCINATION
HR TREND AND LATEST PRACTICES
INFECTION PREVENTION AND CONTROL WEEK
N/A
VIII. OTHER INFORMATION
DATE 5/28/2026
VALUES ORIENTATION WORKSHOP GOVERNMENT OF MARIKINA CITY AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER
NON-ACADEMIC DISTINCTIONS / RECOGNITION
(Write in full)
AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER
PRIME- HR
VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED NUMBER OF
HOURS
OVERIEW OF LABOR LAW
GUIDELINES ON THE IMPLEMENTATION OF THE CITIZEN'S CHARTER ORIENTATION AMANG RODRIGUEZ MEMORIAL MEDICAL CENTER DATA PRIVACY
EXCELLENT CUSTOMER SERVICE
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in full)
N/A N/A
(Continue on separate sheet if necessary)
(Continue on separate sheet if necessary)
DEPARTMENT OF LABOR AND EMPLOYMENT
DEPARTMENT OF LABOR AND EMPLOYMENT
ORGANIZATIONAL BEHAVIOR: ITS IMPORTANCE IN LEADING PEOPLE IN WORK SECTION Webinar on Employer's Virtual Pag-IBIG & Others Pag-IBIG Updates Resignation
a.
If YES, please specify:
b.
If YES, please specify ID No:
c.
If YES, please specify ID No:
REFERENCES (Person not related by consanguinity or affinity to applicant /appointee) OFFICE / RESIDENTIAL ADDRESS
AMANG RODRIGUEZ MEMORIAL MEDICAL
CENTER
AMANG RODRIGUEZ MEMORIAL MEDICAL
CENTER
AMANG RODRIGUEZ MEMORIAL MEDICAL
CENTER
UNIFIED MULTI-PURPOSE ID
35. a. Have you ever been found guilty of any administrative offense? If YES, give details:
Are you related by consanguinity or affinity to the appointing or recommending authority, or to the Bureau or Department where you will be apppointed, Are you a person with disability?
Are you a solo parent?
40.
Have you acquired the status of an immigrant or permanent resident of another country? Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA 7277, as amended); and (c) Expanded Solo Parents Welfare Act (RA 11861), please answer the following items:
Are you a member of any indigenous group?
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 out (abolition) in the public or private sector?
34.
If YES, give details:
chief of bureau or office or to the person who has immediate supervision over you in the Office, a. within the third degree?
b. within the fourth degree (for Local Government Unit - Career Employees)? 36.
PHOTO
NAME CONTACT NO. AND/OR EMAIL
42.
MS. MA. STELLA PRESTO
MR. ROMEO BELLEZA, MD 639*********
MS. CATHERINE MACADANGDANG, MD
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.
a. Have you ever been a candidate in a national or local election held within the last year (except Barangay election)?
37.
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? 38.
If YES, give details:
If YES, give details:
CS FORM 212 (Revised 2025), Page 4 of 4
Person Administering Oath
SUBSCRIBED AND SWORN to before me this, affiant exhibiting his/her validly issued government ID as indicated above. Date Accomplished Right Thumbmark
Date/Place of Issuance: SSS - MARIKINA CITY
Government Issued ID:
ID/License/Passport No.:
5/28/2026
Date Filed:
Status of Case/s:
Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.) PLEASE INDICATE ID Number and Date of Issuance
CRN -0111-0455469-7
Signature (Sign inside the box)
39.
41.
If YES, give details (country):
b. Have you been criminally charged before any court? If YES, give details:
If YES, give details:
If YES, give details:
Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal?
Passport-sized unfiltered digital
picture taken within
the last 6 months
4.5 cm. X 3.5 cm
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES
YES
YES
NO
NO
NO
YES NO
YES NO