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 MENDOZA
NAME EXTENSION (JR., SR)
FIRST NAME CARMELITA

MIDDLE NAME PECSON

3. DATE OF BIRTH
(mm/dd/yyyy) 12/16/1975 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH GUAGUA,PAMPANGA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX
Male ✘ Female
6 CIVIL STATUS
17. RESIDENTIAL ADDRESS 371 PUROK 4
Single ✘ Married House/Block/Lot No. Street
Widowed Separated LAMBAC
Other/s: Subdivision/Village Barangay
7. HEIGHT (m) 5'2" GUAGUA PAMPANGA
City/Municipality Province
8. WEIGHT (kg) 50 KG ZIP CODE 2003

9. BLOOD TYPE B+
18. PERMANENT ADDRESS 371 PUROK 4
House/Block/Lot No. Street
10. GSIS ID NO. 75121600293 LAMBAC
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1400-0026-0643 GUAGUA PAMPANGA

City/Municipality Province

12. PHILHEALTH NO. 07-000017000-1 ZIP CODE 2003

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

14. TIN NO. 203-725-580 20. MOBILE NO. 09193458087

15. AGENCY EMPLOYEE NO. 1862 21. E-MAIL ADDRESS (if any) mpmendoza1216@[Link]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
MENDOZA
FIRST NAME
REMEGIO RAYMOND ANDREI P. MENDOZA 07/26/2000

MIDDLE NAME LANCE HARVEY P. MENDOZA 9/12/2008

SANTOS
OCCUPATION GOVERNMENT EMPLOYEE

EMPLOYER/BUSINESS NAME PROVINCIAL GOVERNMENT OF PAMPANGA

BUSINESS ADDRESS CAPITOL GROUNDS, CITY OF SAN FERNANDO,PAMPANGA

TELEPHONE NO. N/A

24. FATHER'S SURNAME PECSON 10/08/1939

NAME EXTENSION (JR., SR)
FIRST NAME JOSE

MIDDLE NAME BISDA

25. MOTHER'S MAIDEN NAME

SURNAME PECSON 02/01/1946

FIRST NAME NORMA

MIDDLE NAME DELA CRUZ (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY GUAGUA NATIONAL COLLEGES PRIMARY EDUCATION 1983 1989 NA 1989 NA

SECONDARY /
VOCATIONAL GUAGUA NATIONAL COLLEGES HIGH SCHOOL 1989 1992 NA 1992 45

NA NA NA NA NA NA NA
TRADE
BACHELOR OF SCIENCE IN
COURSE
COLLEGE CENTRO ESCOLAR UNIVERSITY 1993 1997 NA 1997 NA
PHARMACY

GRADUATE STUDIES NA NA NA NA NA NA NA
(Continue on separate sheet if necessary)

SIGNATURE DATE November 24, 2023

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
PROFESSIONAL REGULATION COMMISSION-
75.00% JANUARY 1998 MANUEL L. QUEZON UNIVERSITY 0040670
BOARD OF PHARMACY

(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/ PAY SERVICE
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
(Y/ N)
RICARDO P. RODRIGUEZ MEMORIAL
04/05/1999 PRESENT PHARMACIST 11 34,871.00 GRADE 15 PERMANENT Y
HOSPITAL
03/15/1998 11/15/1998 PHARMACIST 1 HOSPITAL OF THE INFANT JESUS 12,000.00 REGULAR N

(Continue on separate sheet if necessary)

SIGNATURE DATE November 24, 2023

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

NA

(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

LICENSING SEMINAR FOR DRUGSTORE AND OUTLET-A.0.56 12/09/2014 12/09/2014 8 TECHNICAL FOOD AND DRUG ADMINISTRATION

LICENSING SEMINAR FOR DRUGSTORE AND OUTLET-A.0.34 06/17/2016 06/17/2016 8 TECHNICAL FOOD AND DRUG ADMINISTRATION
STRENGTHENING HOSPITAL PHARMACY PRACTICE TOWARDS OPTIMUM THE PHILIPPINE SOCIETY OF HOSPITAL
02/24/2017 02/25/2017 16 TECHNICAL
PATIENT CARE PHARMACISTS
TRANSFORMING PROCESSES AND OUTCOMES 04/13/2018 04/13/2018 8 TECHNICAL THE PHILIPPINE PHARMACISTS ASSOCIATION

Antimicrobial Stewardship Training Program for Level 1 Hospitals 11/6/2029 11/8/2029 24 TECHNICAL
JOSE [Link] REGIONAL HOSPITAL

TRAINING OF PHARMACIST FROM LGU 9/25/2020 9/25/2020 8 TECHNICAL

JOSE B. Lingad Regional Hospital

(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 in
(Write in full)
full)
THE PHILIPPINE SOCIETY OF HOSPITAL
COMPUTER LITERATE
PHARMACISTS
DRIVING THE PHILIPPINE PHARMACISTS ASSOCIATION

BAKING

(Continue on separate sheet if necessary)

SIGNATURE DATE November 24, 2023

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 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 from previous job
________________________________
________________________________
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
the last 6 months
Evelyn B. Mallari Cabambangan, Bacolor, Pampanga 09267332074 3.5 cm. X 4.5 cm
(passport size)

DR. ANTONIO B. ONG CITY OF SAN FERNANDO,PAMPANGA 09991561084 With full and handwritten
name tag and signature over
printed name

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 ([Link], GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of
Issuance
Government Issued ID: PRC
ID/License/Passport No.: 40670 Signature (Sign inside the box)
November 24, 2023
Date/Place of Issuance: AUGUST 1997/MANILA,PHILIPPINES
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