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CS FORM 212 (Revised 2003)

PERSONAL DATA SHEET


Print legibly Mark appropriate boxes it!

"ot older t!an # $os% 3%&'$ x (%& '$ (passport si)e)

I. PERSONAL INFORMATION
1. SURNAME FIRST NAME MIDDLE NAME 2. DATE OF BIRTH 3. PLACE OF BIRTH 4. SEX 5. CIVIL STATUS

I I I

13. RESIDENTIAL ADDRESS Male Si !le Ma&&ie# Female "i#$%e# Se'a&a(e# )IP CODE 14. TELEPHONE NO. 15. PERMANENT ADDRESS

I I I II I I

*. CITI)ENSHIP +. HEI,HT -M. /. "EI,HT -0,. 1. BLOOD T2PE

I I I I I

)IPCODE 1*. TELEPHONE NO.

1+. E3MAIL ADDRESS -i4 a 5.I 1/. CELLPHONE NO. -i4 a 5.I 11. A,ENC2 EMPLO2EE NO. 26. TIN

16.,SIS POLIC2 NO. 11. PA,3IBI, ID NO. 12. PHILHEALTH NO.

I I II. FAMILY BACKGROUND 21. NAME OF SPOUSE I OCCUPATION . EMPLO2ER7BUSS. NAME BUSSINESS ADDRESS. TELEPHONE NO..
22. NAME OF CHILD7CHILDREN Da(e $4 Bi&(8 -mm7##75555.

D NAME OFCHILD7CHILDREN

Da(e $4 Bi&(8 -mm7##75555.

09 23. NAMEOF FATHER. 25. PARENTS


ADDRESS

24. FULL MAIDEN NAME OF MOTHER.

III. EDUCATIONAL BACKGROUND 2*.


LEVEL Name $4 S:8$$l -Write in Full. DE,REE 7 COURSE -Write in Full.

Hi!8e;( ,&a#e7 Le<el7 U i(; Ea& e# -I4 $( ,&a#=a(e#.

INCLUSIVE DATES OF ATTENDANCE F&$m. T$.

ACADEMIC HONORS RECEIVED TO.

ELEMENTAR2 SECONDAR2 VOCATIONAL COURSE TRADE COURSE TERTIAR2 ,RADUATE STUDIES 3 Di'l$ma 3 Ma;(e&>; 3 D$:($&a(e

IV. CIVIL SERVICE ELIGIBILITY 2+. CAREER SERVICE7RA 166


-BOARD7BAR. UNDER SPECIALLA"S7CES7CSEE

RATIN,

Da(e $4 E?ami a(i$ 7 C$ 4e&me (

Pla:e $4 E?ami a(i$ 7 C$ 4e&me (

LICENSE -I4 a''li:a@le. N=m@e& Da(e $4 Relea;e

-C$ (i =e $ ;e'a&a(e ;8ee(7i4 e:e;;a&5..

V. WORK EXPERIENCE (Include !"#$%e e& l'(&en%. S%$!% )!'& !ecen% *'!+ e, e!"ence.2/. INCLUSIVE DATES
-mm7##75555. F&$m. T$. POSITION TITLE -"&i(e i 4=ll. DEPARTMENT7A,ENC27OFFICE -"&i(e i 4=ll.

MONTHL2 SALAR2

STATUS OF APPONTMENT

1* O:( 2664 61 Ma& 2664 12 De: 2664 * Se' 2663 12 Ma5 2663 1* Se'( 2662 31 Ma5 2666 21 Ma& 2666 24 Se' 1/ 4 Ma& 13 4 Aa 13 A'& 12 2/ A=! 11 1/ N$< /* 15 O:( /* 26 A= /* 1* A'& +1 1 A'& ++ 1 A'& +3

($ #a(e 1* O:( 2664 61 Ma& 2664 12 De: 2663 25 Se'( 2663 11 Ma5 2663 15 Se'( 2662 36 Ma5 2666 Ma& 2666 + Se' 1/ 3 Ma& 13 Se' 12 A'& 12 A=! /+ 1/ N$< /* 15 O:( /* 1 O:( /4 1* A'& +1 24 Fe@ ++
-C$ (i =e $ ;e'a&a(e ;8ee(7i4 e:e;;a&5..

A))", ('u! ."/n$%u!e0 11111111111111111111111111111111111111111111111111111

D$%e0

22 Fe3!u$!( 2445

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC6NON7GOVERNMENT6PEOPLE6VOLUNTARY ORGANI8ATION6S

21. NAME AND ADDRESS OF OR,ANI)ATION (Write in full)

INCLUSIVE DATES (mm/dd/yyyy) F&$m. T$.

NUMBER OF HOURS

POSITION 7 NATURE OF "OR0

-C$ (i =e $ ;e'a&a(e ;8ee(7i4 e:e;;a&5..

VII. TRAINING PROGRAMS6STUDY6SC9OLARS9IP GRANTS (S%$!% )!'& %:e &'.% !ecen% %!$"n"n/.36.
TITLE OF SEMINAR7CONFERENCE7"OR0SHOP (Write in full) INCLUSIVE DATES (mm/dd/yyyy) NUMBER OF HOURS F&$m. T$.

CONDUCTED7SPONSORED B2 (Write in full)

Vi(al I ;( a # Se:=&i(5 ASEAN P$li:e A#< C$=&;e P$li:e A((a:8B C$=&;e PI OSEC PNP A#< C$=&;e S:$=( Ra !e& Ba;i: C$=&;e C$mma #a (>; S:8$$l P=@li: A44ai&; C&imi al I 4$&ma(i$ H$;(a!e Ne!$(ia(i$ C$=&;e Ba;i: I (el -1.

-C$ (i =e $ ;e'a&a(e ;8ee(7i4 e:e;;a&5..

VIII. OT9ER INFORMATION 31. SPECIAL S0ILLS 7 HOBBIES

32. NON3ACADEMIC DISTINCTIONS 7 RECO,NITION C (Write in full)

33.

MEMBERSHIP IN ASSOCIATION7OR,ANI)ATION (Write in full)

3(% *re yo+ related by 'onsang+inity or a,,inity to any o, t!e ,ollo ing- appointing a+t!ority. re'o$$ending a+t!ority. '!ie,

a% /it!in t!e degree0


(,or "*34O"*5 6O72R"M2"3 2$ployees)

12S

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o, o,,i'e8b+rea+8depart$ent or person !o !as i$$ediate s+pervision over yo+ in t!e O,,i'e. 9+rea+ or :epart$ent !ere yo+ ill be appointed0 3&% >ave yo+ ever been de'lared g+ilty o, any ad$inistrative o,,ense0

b% /it!in t!e ,o+rt! degree0


(,or 5OC*5 6O72R"M2"3 2$ployees)

12S

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4, yo+ ans er is ;12S<. give parti'+lars% ============================== ====================================================================

12S

"O

4, yo+ ans er is ;12S<. give details o, t!e o,,ense ============================ ======================================================================

3#% >ave yo+ ever been 'onvi'ted o, any 'ri$e or violation o, any la . de'ree. ordinan'e or reg+lations by any 'o+rt or trib+nal0 3?% >ave yo+ ever been ,or'ed to retire8 resign or dropped ,ro$ e$ploy$ent in t!e p+bli' or private se'tor0 3@% >ave yo+ ever been a 'andidate in a national or lo'al ele'tion (ex'ept 9arangay ele'tion)0 3A% P+rs+ant to- (a) 4ndigeno+s PeopleBs *'t (R* @3?1)C (b) Magna Carta ,or :isabled Persons (R* ?2??)C and (') Solo Parents /el,are *'t o, 2000 (R* @A?2)D. please ans er t!e ,ollo ing ite$s-

12S

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4, yo+ ans er is ;12S<. give details o, t!e o,,ense ============================ =====================================================================

12S

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4, yo+ ans er is ;12S<. give reason ================================ ======================================================================

12S

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4, yo+ ans er is ;12S<. give date o, ele'tion and ot!er parti'+lars% ================ ==================================================================== a% *re yo+ a $e$ber o, any indigeno+s gro+p0 12S "O 4, yo+r ans er is 12S. please spe'i,y ====================================== b% *re yo+ di,,erently abled0 12S "O 4, yo+r ans er is 12S. please spe'i,y ====================================== '% *re yo+ a solo parent0 12S "O 4, yo+r ans er is 12S. please spe'i,y ====================================== 3252P>O"2 "O%

(0% R2F2R2"C2S (Person not related by 'onsang+inity or a,,inity to appli'ant8 appointee) "*M2 *::R2SS

Police Director Quirino D Dela Torre

DC, Camp Crame, QC

(1% 4 de'lare +nder t!e penalties o, perE+ry t!at t!is Personal :ata S!eet !as been a''o$plis!ed in good ,ait!. veri,ied by $e and to t!e best o, $y kno ledge and belie, is a tr+e. 'orre't and 'o$plete state$ent p+rs+ant to t!e provisions o, pertinent la s. r+les and reg+lations o, t!e Rep+bli' o, t!e P!ilippines% 4 also a+t!ori)e t!e agen'y !ead8 a+t!ori)ed representative to veri,y8 validate t!e 'ontents stated !erein% 4 tr+st t!is in,or$ation s!all re$ain 'on,idential%

Signat+re :ate *''o$plis!ed Co$$+nity 3ax Certi,i'ate 4ss+ed at 4ss+ed on


Rig!t 3!+$b$ark

Solo Parent as de,ined in Se'tion 3 o, Rep+bli' *'t "o% @A?2 re,ers to any individ+al !o ,alls +nder any o, t!e ,ollo ing 'ategoriesa% * o$an !o gives birt! as a res+lt o, rape and ot!er 'ri$es against '!astity even it!o+t a ,inal 'onvi'tion o, t!e o,,ender provided t!e $ot!er keeps and raises t!is '!ild% b% Parent le,t solo or alone it! t!e responsibility o, parent!ood d+e to t!e deat! o, spo+se% '% Parent le,t solo or alone it! t!e responsibility o, parent!ood !ile t!e spo+se is detained. or is serving senten'e ,or a 'ri$inal 'onvi'tion ,or at least one (1) year% d% Parent le,t solo or alone it! t!e responsibility o, parent!ood d+e to p!ysi'al and8or $ental in'apa'ity o, spo+se as 'erti,ied by a p+bli' $edi'al pra'titioner% e% Parent le,t solo or alone it! t!e responsibility o, parent!ood d+e to legal separation or de ,a'to separation ,ro$ spo+se ,or at least one (1) year as long as !e8s!e is entr+sted it! t!e '+stody o, t!e '!ildren% ,% Parent le,t solo or alone it! t!e responsibility o, parent!ood d+e to t!e de'laration o, n+llity or ann+l$ent o, $arriage as de'lared by a 'o+rt or by a '!+r'! as long as !e8s!e is entr+sted it! t!e '+stody o, t!e '!ildren% g% Parent le,t solo or alone it! t!e responsibility o, parent!ood d+e to abandon$ent o, spo+se ,or at least one (1) year% !% Parent le,t solo or alone it! t!e responsibility o, parent!ood d+e to +n$arried $ot!er8,at!er !o !as pre,erred to keep and rear !is8!er '!ildren instead o, !aving ot!ers 'are or give t!e$ +p to a el,are instit+tion% i% *ny ot!er person !o solely provides parental 'are and s+pport to a '!ild8'!ildren and any ,a$ily $e$ber !o ass+$es t!e responsibility o, !ead o, ,a$ily as a res+lt o, t!e deat!. abandon$ent. disappearan'e or prolong absen'e o, t!e parents or solo parent%

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