CS Form 212 (Revised 2003)

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes I. PERSONAL INFORMATION 1 LAST NAME FIRST NAME MIDDLE NAME DATE OF BIRTH PLACE OF BIRTH SEX CIVIL STATUS with X

not older than 6 mos 3.5 cm x 4.5 cm (passport size)

2 3 4 5

13 RESIDENTIAL ADDRESS Male Single Married Female Widowed

Separated

ZIP CODE 14 TELEPHONE NO. 15 PREMANENT ADDRESS ZIP CODE TELEPHONE NO.
E-MAIL ADDRESS (if any)

6 CITIZENSHIP 7 HEIGHT (m) 8 WEIGHT (kg) 9 BLOOD TYPE 10 GSIS POLICY NO. 11 PAG-IBIG ID NO. 12 PHILHEALTH NO. II FAMILY BACKGROUND 21 NAME OF SPOUSE OCCUPATION
EMPLOYER'S BUS. NAME

16 17 18 19 20

Cellphone no. (if any)

AGENCY EMPLOYEE NO.

TIN

BUSINESS ADDRESS TELEPHONE NO. 22 NAME OF CHILDREN

Date of Birth (mm/dd/yy)

NAME OF CHILDREN

Date of Birth (mm/dd/yy)

23 NAME OF FATHER 25 PARENTS ADDRESS III EDUCATIONAL BACKGROUND 26

(Continue on separate sheet if necessary) 25 FULL MAIDEN NAME OF MOTHER

LEVEL

Name of School
(Write in full)

DEGREE/COURSE
(Write in full)

Highest INCLUSIVE DATE Grade/ OF Level/Units ATTENDANCE Earned (if not graduated)

From

To

ELEMENTARY SECONDARY VOCATIONAL/ TRADE COURSE TERTIARY

GRADUATE STUDIES

Diploma Master's Doctorate

Non-Degree Course*

*(course taken from tertiary education but not classified as Graduate Studies) (Continue on separate sheet if necessary

not older than 6 mos

5 cm x 4.5 cm (passport size)

f Birth (mm/dd/yy)

SCHOLARSHIP /ACADEMIC HONORS RECEIVED

IV CIVIL SERVICE ELIGIBILITY 27 CAREER SERVICE/RA 1080

(BOARD/BAR) UNDER SPECIAL LAWS/CES/CSEE

RATING

DATE OF EXAMINATION/ CONFERNMENT

PLACE OF EXAMINATION/ CONFERNMENT

LICENSE (if applicable) Number

(Continue on separate sheet if necessary) V. WORK EXPERIENCE (Include private employment. Start from most recent work experience.) 28 INCLUSIVE DATES POSITION TITLE DEPARTMENT/AGENCY/OFFICE (Write MONTHLY (mm/dd/yy) (Write in full) in full) SALARY From To

(Continue on separate sheet if necessary)

Affix your signature:

Date:

ENSE (if applicable)

Date of release

STATUS OF APPOINTMENT

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC/NON GOVERNMENT/PEOPLE/VOLUNTARY ORGANIZATIONS 29 INCLUSIVE DATES NUMBER OF POSITION/NATURE OF NAME AND ADDRESS OF ORGANIZATION (Write in full) (mm/dd/yy) HOURS WORK From To

(Continue on separate sheet, if necessary) VII. TRAINING PROGRAMS/STUDY/SCHOLARSHIP GRANTS (Start from the most recent training) 30 TITLE OF SEMINAR/CONFERENCE/WORKSHOP (Write in full) INCLUSIVE DATES OF ATTENDANCE From To NUMBER OF HOURS
CONDUCTED/SPONSORED BY (Write in full)

(Continue on separate sheet, if necessary) VIII.OTHER INFORMATION 31 SPECIAL SKILLS/HOBBIES

32

NON-ACADEMIC DISTINCTIONS/RECOGNITIONS in full)

33
(Write

MEMBERSHIP

IN ASSOCIATION/ORGANIZATION (Write in full)

RGANIZATIONS

SITION/NATURE OF WORK

NDUCTED/SPONSORED BY (Write in full)

MBERSHIP

ATION/ORGANIZATION (Write in full)

34 Are you realated by consaguinity or affinity to any of the following: appointing authority, recommending authority, chief of office/bureau/department or person who has immediate supervision over you in the Office, Bureau or Department where you will be appointed? 35 Have you been declared guilty of any administrative offense?

a. Within the third degree?

(for NATIONAL GOVERNMENT employees

YES YES ________________

b. Within the fourth degree?

(for LOCAL GOVERNMENT employees

If your answer is "YES", give particulars

YES If your answer is "YES", give details of the offense

36 Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulations by any court or tribunal?

YES If your answer is "YES", give details of the offense

37 Have you ever been forced to retire/resign or dropped from employment in the public or private sector? 38 Have you ever been a candidate in the national or local election (except barangay election)?

YES If your answer is "YES", give reasons

YES If your answer is "YES", give reasons

39 Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA 7277); and Solo Parents Welfare Act of 2000 (RA8972); please answer the following items:

a. Are you a member of any indegenous group? If your answer is "YES", please specify b. Are you differently abled? If your answer is "YES", please specify c. Are you a solo parent? If your answer is "YES", please specify

YES

YES YES

40 REFERENCES (Persons not related by consaguinity or affinity to applicant/appointee) NAME Antonia Acosta Remagina R. Rosario ADDRESS Molina St. Viente Reales, Val. City P. Gregorio St. Lingunan Val. City TELEPHONE NO. 9323325808 9239044351

41 I declare under the penalties of perjury that this Personal Data Sheet has been accomplished in good faith, verified by me and to the best of my knowledge and belief is a true, correct and complete statement pursuant to the provision of pertinent laws, rules and regulations of the Republic of the Philippines. I also authorize the agency head/authorized representative to verily/validate the contents stated herein. I trust that this information shall remain confidential. Signature Date Accomplished Community Tax Certificate No. Issued at Issued on
Solo Parent as directed in Section 3 of Republic Act No. 8972 refers to any individual who falls under any of the following categories A woman who gives birth as a result of rape and other crimes against chastity even without a final conviction of the offender. Provided that the mother keeps and raises the child; Parent left solo or alone with the responsibility of parenthood due to the death of spouse; Parent left solo or alone with the responsibility of parenthood while the spouse is detained, or is serving sentence for a criminal conviction for at least one (1) year; Parent left solo or alone with the responsibility of parenthood due to physical and/or mental incapacity of spouse as certified by a public medical practitioner; Parent left sol or alone with the responsibility of parenthood due to legal separation or de facto separation from spouse for at least one (1) year for as long as he/she is entrusted Parent left solo or alone with the responsibility of parenthood due to declaration of nullity or annulment of marriage as decreed by a court or by a church as long as he/she is entrusted with the custody of the children; Parent left solo or alone with the responsibility of parenthood due to abandonement of spouse for at least one (1) year; Parent left solo or alone with the responsibility of parenthood due to unmaried mother/father who has preferred to keep and rear his/her child/children instead of having others care for them or give them up to a welfare institution;

Right Thumbmark

(a) (b) ( c) (d) (e) (f) (g) (h)

(I) (j)

Any other person who solely provided parental care and support to a child or children; and Any family member who assumes responsibility of head of the family as a result of the death, abandonement, disappearance or prolonged absence of solo parent.

NO NO

______________

NO

NO

NO

NO

NO

NO NO

ELEPHONE NO. 9323325808 9239044351

ood faith, verified uant to the

erein. I trust that

Right Thumbmark

he mother keeps and

at least one (1) year;

cal practitioner; ar for as long as he/she is

by a church as long as

/children instead of having

ance or prolonged