1. CS ID No.(to be filled up byCSC)Birth:Province:No:(kg):B+12. G20. Ema lany):No :No (if any):No :Employee NSurname:Surname:1/19/2015www.ejobs.doh.gov.ph/ejobs/applicant/PDSPrint.php?operation=printCSFORM212(Revised 2005)PERSONAL DATA SHEETPrint legibly. Mark appropriate boxes with"[/]" and use separate sheet ifnecessary.I. PERSONAL INFORMATION2. Surname:bialbaFirst Name:daisymae3.NameMiddle Name: ramirezExtensionna (e.g.Jr.,Sr.):4. Date OfBirth1970-05-11 (mm/dd/yyyy):16. Residential #42N. zamora st. sfdm Address:q.c.,5. Place ofpaltok sfdm, CITY OF MANILA, MANILA, NCR, FIRST DISTRICT6. Sex:FEMALEZipCode:11057. Civil Status: MARRIED17. Telephone8. Citizenship: Filipino18. Permanent 342N. zamora st. sfdm. Address:q.c., ,9. Height (m):0.0010. Weight52.27ZipCode:011. Blood19. Telephone Type:No:No.: SIS IDAddressi(ifdaisybialba@yahoo.com13..Pagibig ID1070-0040-216021. Cellphone0927-139-221514..PhilHealth19-051985867-722. Agency o.: n/a15. SSS No:03-9266362-123. TIN:158-431-909II. FAMINlYBACKGROUND24. Spouse'sbialba26. Father'sramirez(deceased)First Name:roelFirst Name:rubenMiddle Name: rodriguezMiddleName:cajucomOccupation:businessmanEmployer27. Mother'shttp://www.ejobs.doh.gov.ph/ejobs/applicant/PDSPrint.php?operation=print1/7BusinessToFrom0Place ofRatingExamination/Conferment1/19/2015www.ejobs.doh.gov.ph/ejobs/applicant/PDSPrint.php?operation=printName:selfemployedSurname:ramirezAddress:342n. zamora st. sfdmq.c. First Name:emelitaTelephone No:Middle Name: bartolomeApplicant ChildNAME OF CHILD(Write fullname andlist all) DATE OF BIRTH (mm/dd/yyyy)(Continue onseparate sheet ifnecessary)III. EDUCATIONAL BACKGROUNDName of28. LevelSchool (Write infull) Degree Course (Write in full) Yeargraduated HighestUnits (ifGrade Earned graduated) Scholarship / Academic Honors Received08doctor ofuniversitytomasDOCTORALofsto.philosophy 20121.06620042012 n/a07universitymaster ofMASTERALofsto.arts in19981.03619931998 N/A tomasnursing06 COLLEGE united doctors medical center bachelor ofscience in 19911.o nursing top 13 -19871991 leadershipawardeefamily 09 OTHERS cliniccolleges ab psychology 1.25919991999 N/Anationalteacherprogram09 OTHERS universityeducation 20143.5620142014 N/A(Continue onseparate sheet ifnecessary)IV. CIVIL SERVICE ELIGIBILITYCareerService /Date of RA1080 (BoardExamination Bar)(UnderSpecial/Laws / CES / CSEEConferment License Number Date of ReleasePRC79.80 1992-05-31 manila0202670 1993-01-22(Continue onseparate sheet ifnecessary)http://www.ejobs.doh.gov.ph/ejobs/applicant/PDSPrint.php?operation=print2/7Gov'tToService(Yes/No)04-3004-30time2014-2015-professor35000.00fulltime2004-2010-nursing2009-2010-nursing20000.00part time2000-2004-eduquality12-3112-31HOSPITAL04-3009-30education2002-2003-2000-2004-nurse2000-2004-1/19/2015www.ejobs.doh.gov.ph/ejobs/applicant/PDSPrint.php?operation=printV. Work Experience (Include private employment. Start fromyourcurrent work)Salary PositionGrade &30.TitleDepartment/Agency/Office/CompanyMonthly StepStatus of From(Write in(Write infull)SalaryIncrementAppointmentfull) (format "00-0")2010-2013-professorst. mary's college, quezoncity35000.00regular - full05-0107-01professorpamantasannglungsod ngmaynila18000.00part time12013-2015-nationaluniversity- college of 05-0107-01education/graduate schooldean,04-3004-30college ofN/A40000.00regular10-0107-01consultanttaguiggeneralhospital10000.00honorary1nurse2005-2011-licensurekeiserworthreview center/vbp review 12-3112-31examination centerreviewerassistant chiefnurse09-3003-31for cationdr. jesus c. delgado memorialhospital25000.00regular and training2001-2003-managementDR. JESUS DELGADO MEMORIAL 0.00honorary trainer2000-2000-and training dr. jesus c. delgado memorialhospital16000.00regular coordinator05-3109-30lecturertrinitycollege10000.00part timeinfection03-3103-31controldr. jesus c. delgado memorialhospital0.02regular04-0104-01IV trainerdr. jesus c. delgado memorialhospital0.00regular1993-2000-Clinical instructor tofamilyclinic inc.16000.00regularhttp://www.ejobs.doh.gov.ph/ejobs/applicant/PDSPrint.php?operation=print3/71992-1993-iccu-picuOrganizationDatesif HoursWorkaged0110-01trainingthe healthcarfoundation0102-15trainingthe healthcar0.16communityservicethe Needy1511-150910-090.24communityservice0.24communityserviceElderly0412-040.16communityservice0.40communityservice0.24communityservicepaltok3107-31paltok3009-300.241/19/2015www.ejobs.doh.gov.ph/ejobs/applicant/PDSPrint.php?operation=print03-0103-30assistant professor06-0103-30staffnursedelos santos medicalcenter (iccu-picu) 5000.00probitionary(Continue onseparate sheet ifnecessary)VI. Voluntary Work orInvolvement inCivic/Non-Government/People/Voluntary Organizations31. Name & Address ofInclusiveToNumberPosition/ Nature of (Write infull)FromKanlungannimaria home for the2011-10-2012-150.00 providers/communitye service/caringthe elderlyuplift communitydevelopment2011-10-2012-60.00providers/communitye service/caringthe elderlyBahayKanlunganniMaria 2011-08-2011-Domenica The CamillianSisters 31 08-31Missionaries ofCharityHome for 2011-11-2011-0.16communityserviceAnawimHome ofGods Poor2011-10-2011-0.16communityserviceSt. Lorenzo RuizHome for the 2011-05-2011-ElderlyLittle Sisters ofthe Poor 31 06-01St. JosephHome for the Elderly 2011-08-2011-Little Sister ofthe Poor 31 08-31House ofSomangHome for the2011-11-2011-0.40communityserviceBlue Whale MissionofOur Lady, 2011-09-2011-Inc Home for the Elderly 30 09-30Missionaries ofCharityHome for 2011-10-2011-the Sick and Aged 03 12-31- Missionaries ofCharityHome for2011-10-2011-the Sick and the Aged 31 10-31communityservice for barangay2013-07-2013-0.32dentalmissioncommunityservice for barangay2013-09-2013-0.24medicalmissioncommunityservice for barangay2013-07-2013-feedingprogramfor the paltok3107-31childrenofbarangaypaltokhttp://www.ejobs.doh.gov.ph/ejobs/applicant/PDSPrint.php?operation=print4/7paltok3107-31livelihood programfor tpaltok3009-302011-10-2011-3110-3133. Special34. NonAcademicinfull)1/19/2015www.ejobs.doh.gov.ph/ejobs/applicant/PDSPrint.php?operation=printcommunityservice for barangay paltok2013-07-312013-07-310.24livelihood programfor the communityofbarangay paltokcommunityservice for barangay2013-07-2013-0.24communityofbarangayhe paltokcommunityservice for barangay2013-06-2013-4.00free-nurse stationled clinicoffice ofthe vice mayor quezoncityantidrugabuse advisory0.80volunteer council(Continue onseparate sheet ifnecessary)VII. Training Programs (Start fromthe most recent training)32. Title of Seminar/Conference/Workshop/Short Courses(Write infull) NumberFromToof Hours Conducted/Sponsored by(Write infull)(Continue onseparate sheet ifnecessary)VIII. OtherInformation33. Special Skills/Hobbiesreading, playingpiano, baking, playingkey boards, playing volleyball 34. NonAcademic Distinction/Recognition (Write infull)leadership awardee 35. Memberin Association/Organization (Write infull)Philippine Nurses Association (PNA) AssociationofDeans ofthe Philippine Colleges ofNursing)ADPCN(Continue onseparate sheet ifnecessary)32. Title of Seminar/Conference/Workshop/Short Courses(Write infull) NumberFromToof Hours Conducted/Sponsored by(Write infull)VIII. OtherInformation35. MemberinSkills/HobbiesDistinction/RecognitionAssociation/Organization(Writehttp://www.ejobs.doh.gov.ph/ejobs/applicant/PDSPrint.php?operation=print5/7IfYes,pleasespecify:IfYes,IfYes,IfYes,1/19/2015www.ejobs.doh.gov.ph/ejobs/applicant/PDSPrint.php?operation=printreading, playingpiano, baking, playingkey boards, playing volleyballleadership awardeePhilippine Nurses Association (PNA) AssociationofDeans ofthe Philippine Colleges ofNursing )ADPCN36. Are yourelated byconsaguinityor affinityto anyofthe following:a. Within the third degree (for NationalGovernment Employees):appointingauthority, recommendingauthority, chiefofoffice/bureau/department or personwho has immediate supervisionover youinthe Office, Bureauor Department where you willbe appointed?b. Withinthe fourthdegree (for LocalGovernment Employees):appointing IfYes, authorityor recommendingauthoritywhere youwillbe appointed? pleasespecify:37. a. Have youever beenformallycharged?please specify:b. Have youever beenguiltyofanyadministrative offense?please specify:38. Have youever beenconvicted ofanycrime or violationofanylaw,decree, IfYes, ordinance or regulationbyanycourt ortribunal? pleasespecify:39. Have youever beenseparated fromthe service inanyofthe following modes:resignation, retirement, dropped fromthe rolls, dismissal,termination,IfYes, end ofterm, finished contract, AWOLor phased out, inthe public or privateplease sector?specify:40. Have youever beena candidate ina nationalor localelection(except IfYes, BarangayElection)? pleasespecify:41. Pursuant to:(a) Indigenous Peoples Act(RA 8371);(b)Magna Carta forDisabled Persons(RA7277); and (c)Solo Parents Welfare Act of2000IfYes, (RA8972), please answer the followringitems:a. Areyoua member ofanyplease indigenous group?specify:b. Are youdifferentlyabled?please specify:http://www.ejobs.doh.gov.ph/ejobs/applicant/PDSPrint.php?operation=print6/71/19/2015www.ejobs.doh.gov.ph/ejobs/applicant/PDSPrint.php?operation=printc. Are youa solo parent?IfYes, please specify:42. References (Personnot relatedby consaguinity of affinity to applicant/appointee)NameAddressTel. No.43. I declare under oaththat this PersonalData Sheet ha been accomplished byme,and is a true, correct and complete pursuant to the provisions of pertinent laws,rules and regulations ofthe Republic ofthe Philippines.I also authorized the agencyhead / authorized representative to verify/ validate thecontents stated herein. I trust that this informationshallremain confidential.Photo:CommunityTaxCertificate No.Issued At0000-00-00Issued On(mm/dd/yyyy) SIGNATURE (Signinside the box)0000-00-00Date Accomplished RIGHT THUMBMARKCSFORM212(Revised 2005)Backhttp://www.ejobs.doh.gov.ph/ejobs/applicant/PDSPrint.php?operation=print7/7