CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misinterpretation 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 BANCALE
NAME EXTENSION (JR., SR)
FIRST NAME ANGELI

MIDDLE NAME DE OCAMPO

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
JUNE 15, 1989 by birth by naturalization
4. PLACE OF BIRTH SUBIC ZAMBALES If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS 29 KESSING STREET

Widowed Separated House/Block/Lot No. Street
NEW ASINAN
Other/s:
Subdivision/Village Barangay
OLONGAPO CITY ZAMBALES
7. HEIGHT (m) 157 cm
City/Municipality Province
8. WEIGHT (kg) 72 kgs ZIP CODE 2200
18. PERMANENT ADDRESS 29 KESSING STREET
9. BLOOD TYPE B+
House/Block/Lot No. Street
NEW ASINAN
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121189036612 OLONGAPO CITY ZAMBALES

City/Municipality Province
12. PHILHEALTH NO. 070254766222 ZIP CODE 2200

13. SSS NO. 0227492679 19. TELEPHONE NO. N/A

14. TIN NO. 281080422 20. MOBILE NO. 09501488786

15. AGENCY EMPLOYEE NO. n/a 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME BANCALE 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) MICHAELA JANELLE LOUISE D. BANCALE
FIRST NAME LITO 03/15/2015

MIDDLE NAME JERUSALEM

OCCUPATION BUILDING ELECTRICIAN

EMPLOYER/BUSINESS NAME COMMSEC INC

BUSINESS ADDRESS AURORA BLVD. PASAY METRO MANILA

TELEPHONE NO. N/A

24. FATHER'S SURNAME DE OCAMPO

NAME EXTENSION (JR., SR)
FIRST NAME MICHAEL

MIDDLE NAME ISHIKAWA

25. MOTHER'S MAIDEN NAME MARILOU FLORES RIEGO

SURNAME DE OCAMPO

FIRST NAME MARILOU

MIDDLE NAME RIEGO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

 HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
UNITS ACADEMIC
LEVEL (Write in full) EARNED
GRADUATED
HONORS
(Write in full) (if not RECEIVED
From To
graduated)
3RD
ST. JOSEPH SCHOOL ELEMENTARY
ELEMENTARY
DEPARTMENT
PRIMARY 06/14/1996 03/22/2002 N/A 2002 HONORABLE
MENTION
VOCATIONAL / LITURGICAL
SECONDARY ST JOSEPH COLLEGE OLONGAPO SECONDARY 06/14/2002 03/26/2006 N/A 2006 AWARDEE

N/A

TRADE FAR EASTERN UNIVERSITY / PERPETUAL

COLLEGE
COURSE HELP COLLEGE OF MANILA
BACHELOR OF SCIENCE IN NURSING 06/14/2006 10/26/2011 N/A 2011 N/A

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE SEPTEMBER 12, 2021

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

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/ SERVICE
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY PAY GRADE (if STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To
(Y/ N)
JANUARY 25, MARCH 05,
2021 2021
MR-OPV VACCINATOR Department of Health 30.00 N/A JOB ORDER YES
JULY 06, DECEMBER
2020 31, 2020
Public Health Associates Department of Health 32, 057.55 N/A JOB ORDER YES
FEBRUARY JUNE 30,
11, 2020 2020
Public Health Associates Department of Health 32, 057.55 N/A JOB ORDER YES
FEBRUARY JUNE 30, Olongapo Healthcare Specialist Diagnostic
11, 2020 2020
Public Health Associates 32, 057.55 N/A JOB ORDER YES
and Laboratory
JUNE 15, Olongapo Healthcare Specialist Diagnostic
July 09, 2018
2019
Clinic Nurse 15, 000 N/A JOB ORDER NO
and Laboratory
October 10, Unihealth Baypointe Hospital and Medical
2016
July 31, 2018 Staff Nurse 12.00 N/A JOB ORDER NO
Center

(Continue on separate sheet if necessary)

SIGNATURE DATE SEPTEMBER 12, 2021
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (Write in
full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
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
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) From To Technical/etc)

Integrated Tuberculosis Information System (ITIS) October 16, 2019 October 17, 2019 16 hours TECHNICAL Department of Health

Infusion Therapy Ethico Legal Implications (UPDATES) May 22, 2018 May 22, 2018 5 hours TECHNICAL
ACE Baypointe Hospital and Medical Center
Basic Life Support / Advance Cardiac Life Support
ACE Baypointe Hospital and Medical
February 24, 2017 February 26, 2017 24 hours TECHNICAL
Center
Basic intravenous Theraphy
V.L. Makabali Memorial Hospital, Inc. San Fernando
July 13, 2016 July 15, 2016 24 hours TECHNICAL Pampanga

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE SEPTEMBER 12, 2021

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 ✘ NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘ NO
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
YES ✘ NO
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, YES ✘ NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or If YES, give details:
phased 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 YES ✘ NO
(except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
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?
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
a.
items:
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.

97 GALLAGHER ST. EAST

Dr. Elizabeth M. Carillo TAPINAC OLONGAPO CITY
9173123079

ACE Baypointe Hospital and Medical

Bernard Bibanco Center
9479466399

San Juan De Dios Hospital Pasay

Jendeline De Leon Sandhu Metro Manila
9959348632
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 PHOTO
filing of 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.: 0883614

Signature (Sign inside the box)
09-12-2021
Date/Place of Issuance: 07/13/2016
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