CS FORM 212 (Revised 2005

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PERSONAL DATA SHEET
Print legibly. Mark appropriate boxes with " " and use separate sheet if necessary. 1. CS ID No. (to be filled up by CSC)

I. PERSONAL INFORMATION
2. SURNAME FIRST NAME MIDDLE NAME

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| 3. NAME EXTENSION (e.g. Jr., Sr.) | | | | | |

4. DATE OF BIRTH (mm/dd/yyyy) 5. PLACE OF BIRTH 6. SEX 7. CIVIL STATUS

16. RESIDENTIAL ADDRESS

Male Single Married

Fem ale Widowed Separated
ZIP CODE 17. TELEPHONE NO.

18. Annulled Others, specify ___________ PERMANENT ADDRESS 8. CITIZENSHIP 9. HEIGHT (m) 10. WEIGHT (kg) 11. BLOOD TYPE 12. GSIS ID NO. 13. PAG-IBIG ID NO. 14. PHILHEALTH NO. 15. SSS NO. ZIP CODE 19. TELEPHONE NO. 20. E-MAIL ADDRESS (if any) 21. CELLPHONE NO. (if any) 22. AGENCY EMPLOYEE NO. 23. TIN

II. FAMILY BACKGROUND
24.SPOUSE'S SURNAME FIRST NAME MIDDLE NAME OCCUPATION EMPLOYER/BUS. NAME BUSINESS ADDRESS TELEPHONE NO. (Continue on separate sheet if necessary) 26. FATHER'S SURNAME FIRST NAME MIDDLE NAME 27. MOTHER'S MAIDEN NAME SURNAME FIRST NAME MIDDLE NAME YEAR GRADUATE D DEGREE COURSE (Write in full) 25. NAME OF CHILD (Write full name and list DATE OF BIRTH (mm/dd/yyyy) all)

/ / / / / / / / / / / / /
(Continue on separate sheet if necessary) HIGHEST GRADE/ LEVEL/ UNITS EARNED (if not graduated)

/ / / / / / / / / / / / /

III. EDUCATIONAL BACKGROUND
28. LEVEL NAME OF SCHOOL (Write in full)

INCLUSIVE DATES OF ATTENDANCE From To

SCHOLARSHIP/ ACADEMIC HONORS RECEIVED

ELEMENTARY

(if graduated )

SECONDARY / VOCATIONAL

COLLEGE TRADE COURSE

GRADUATE STUDIES

(Continue on separate sheet if necessary) Page 1 of 4

IV. INCLUSIVE DATES (mm/dd/yyyy) From To POSITION TITLE (Write in full) DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY (Write in SALARY full) SALARY GRADE & STATUS OF STEP APPOINTMEN INCREMENT T (Format "000") GOV'T SERVICE / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / (Continue on separate sheet if necessary) (Yes / No) CS FORM 212 (Revised 2005). Start from your current work) 30. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEE RATING DATE OF EXAMINATIO N/ CONFERMENT LICENSE (if applicable) PLACE OF EXAMINATION / CONFERMENT NUMBER DATE OF RELEASE (Continue on separate sheet if necessary) V. Page 2 of 4 . CIVIL SERVICE ELIGIBILITY 29. WORK EXPERIENCE (Include private employment.

TRAINING PROGRAMS (Start from the most recent training. OTHER INFORMATION NON-ACADEMIC DISTINCTIONS / RECOGNITION: 33. Page 3 of 4 . SPECIAL SKILLS / HOBBIES: 34. (Write in full) 35. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S INCLUSIVE DATES 31.) 32. MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full) (Continue on separate sheet if necessary) CS FORM 212 (Revised 2005). TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write in full) INCLUSIVE DATES OF ATTENDANCE From (mm/dd/yyyy) To NUMBER CONDUCTED/ SPONSORED BY OF HOURS (Write in full) / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / (Continue on separate sheet if necessary) VIII.VI. NAME & ADDRESS OF ORGANIZATION (Write in full) (mm/dd/yyyy) From To NUMBER OF HOURS POSITION / NATURE OF WORK / / / / / / / / / / / / / / / / / / / / (Continue on separate sheet if necessary) VII.

I declare under oath that this Personal Data Sheet has been accomplished by me. Have you ever been convicted of any crime or violation of any law. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee) NAME ADDRESS TEL. 42. please answer the following items: Are you a member of any indigenous group? Are you differently abled? Are you a solo parent? YES NO If YES. NO. Within the third degree (for National Government Employees): appointing authority. please specify: ____________________ YES NO If YES. give details: ________________________________ ________________________________ YES NO If YES. termination. Have you ever been guilty of any administrative offense? 38. ISSUED AT SIGNATURE (Sign inside the box) / / DATE ACCOMPLISHED RIGHT THUMBMARK ISSUED ON (mm/dd/yyyy) CS FORM 212 (Revised 2005). Have you ever been formally charged? b. c. ordinance or regulation by any court or tribunal? 39. in the public or private sector? If YES. give details: ________________________________ ________________________________ YES NO a. PHOTO COMMUNITY TAX CERTIFICATE NO. dropped from the rolls. Have you ever been a candidate in a national or local election (except Barangay election)? If YES. AWOL or phased out. Are you related by consanguinity or affinity to any of the following : YES NO If YES. decree. rules and regulations of the Republic of the Philippines. retirement. Bureau or Department where you will be appointed? the fourth degree (for Local Government Employees): appointing authority or recommending authority where you will be appointed? b. X 4. I trust that this information shall remain confidential. Within 37 a. give details: ________________________________ ________________________________ YES NO 40. recommending authority. Have you ever been separated from the service in any of the following modes: resignation. Page 4 of 4 . give details: ____________________________________ _ ____________________________________ _ ____________________________________ YES NO _ If YES.5 cm (passport size) Computer generated or xerox copy of picture is not acceptable 43. chief of office/bureau/department or person who has immediate supervision over you in the Office. I also authorize the agency head / authorized representative to verify / validate the contents stated herein. give details: ________________________________ ________________________________ YES NO If YES.5 cm.36. and is a true. give details: ________________________________ ________________________________ 41. finished contract. dismissal. ID picture taken within the last 6 months 3. give details: ____________________________________ _ ____________________________________ _ YES NO ____________________________________ If _ YES. please specify: ____________________ a. b. Pursuant to: (a) Indigenous People's Act (RA 8371). (b) Magna Carta for Disabled Persons (RA 7277). correct and complete statement pursuant to the provisions of pertinent laws. and (c) Solo Parents Welfare Act of 2000 (RA 8972). please specify: ____________________ YES NO If YES. end of term.

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