Page 1768 - AACCUP Accreditation_AreaIV

CS Form No. 212
PERSONAL DATA SHEET
Revised 2017

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 OBIÑA
FIRST NAME EDMUNDO NAME EXTENSION (JR., SR)
MIDDLE NAME ATIP
3. DATE OF BIRTH 09/09/1960
(mm/dd/yyyy) 16. CITIZENSHIP Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH IPIL, ECHAGUE, ISABELA If holder of dual citizenship, Pls. indicate country:
5. SEX Male Female please indicate the details.
6 CIVIL STATUS Single Married 17. RESIDENTIAL ADDRESS
Widowed Separated House/Block/Lot No. Street
Other/s: SILUAN SUR
Subdivision/Village Barangay
7. HEIGHT (m) 1.7 ECHAGUE ISABELA
City/Municipality Province
8. WEIGHT (kg) 66 ZIP CODE 3309
9. BLOOD TYPE B 18. PERMANENT ADDRESS SILUAN SUR

10. GSIS ID NO. Subdivision/Village Barangay
11. PAG-IBIG ID NO. 0101-0129559-08 ECHAGUE ISABELA
City/Municipality Province
12. PHILHEALTH NO. 06-000042060-6 ZIP CODE 3309
13. SSS NO. N/A 19. TELEPHONE NO.

14. TIN NO. 128-363-001 20. MOBILE NO.

15. AGENCY EMPLOYEE NO. EAO090960 21. E-MAIL ADDRESS (if any) obiňaedmundo@yahoo.com
II. FAMILY BACKGROUND san
22. SPOUSE'S SURNAME GUZMAN 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
FIRST NAME ANTONETTE JOMAE G. OBIÑA 05/01/1981
MIDDLE NAME DUMALIANG JERIL FAYE G. OBIÑA 04/20/1984
OCCUPATION DENTIST EDMUNDO ANTONIO G. OBIÑA 23/12/1986
EMPLOYER/BUSINESS NAME ISABELA STATE UNIVERSITY RICHMUND G. OBIÑA 06/07/1988
BUSINESS ADDRESS SAN FABIAN, ECHAGUE, ISABELA
TELEPHONE NO.
24. FATHER'S SURNAME OBIÑA
FIRST NAME FRANCISCO (DECEASED) NAME EXTENSION (JR., SR)
MIDDLE NAME REYES
25. MOTHER'S MAIDEN NAME
SURNAME ATIP
FIRST NAME GORGONIA (DECEASED)
MIDDLE NAME MANGANTULAO (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
HIGHEST SCHOLARSHIP/

PERIOD OF ATTENDANCE

C
A
D
U
/
D
TI
ON
A
S
26. NAME OF SCHOOL YEAR ACADEMIC
B

E
I
C
E

S
E

E
/
GR
E
R
OU
C
LEVEL/
LEVEL
(Write in full) (Write in full) UNITS GRADUATED HONORS
From To EARNED RECEIVED