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CS FORM 212 (Revised 2005

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PERSONAL DATA SHEET
Print legibly. Mark appropriate boxes q with "P " 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 | | | | | | | | | | | | | | | | | 3. NAME EXTENSION (e.g. Jr., Sr.)

4. DATE OF BIRTH (mm/dd/yyyy) / / 16. RESIDENTIAL ADDRESS

5. PLACE OF BIRTH

6. SEX

7. CIVIL STATUS qWidowed
qSingle ZIP CODE

qMarried qSeparated 17. TELEPHONE NO.

qAnnulled q Others, specify ___________ 18. PERMANENT ADDRESS

8. CITIZENSHIP

9. HEIGHT (m)

10. WEIGHT (kg) ZIP CODE

11. BLOOD TYPE 19. TELEPHONE NO.

12. GSIS ID NO. 20. E-MAIL ADDRESS (if any)

13. PAG-IBIG ID NO. 21. CELLPHONE NO. (if any)

14. PHILHEALTH NO. 22. AGENCY EMPLOYEE NO.

15. SSS NO. 23. TIN

II. FAMILY BACKGROUND
24. SPOUSE'S SURNAME 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

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 (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND YEAR
GRADUATED
HIGHEST GRADE/ INCLUSIVE DATES OF
28. NAME OF SCHOOL DEGREE COURSE SCHOLARSHIP/
LEVEL/ ATTENDANCE
LEVEL (Write in (Write in full) ACADEMIC HONORS
UNITS EARNED
full) From To RECEIVED
(if not graduated)

(if graduated)
ELEMENTARY

SECONDARY
VOCATIONAL /

TRADE
COLLEGE
COURSE

GRADUATE STUDIES

(Continue on separate sheet if necessary)
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INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY SALARY GRADE (mm/dd/yyyy) MONTHLY & STEP STATUS OF SALARY INCREMENT APPOINTMENT (Write in full) (Write in full) (Format "00-0") From To (Yes / No) / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / (Continue on separate sheet if necessary) CS FORM 212 (Revised 2005). DATE OF LICENSE (if applicable) CAREER SERVICE/ RA 1080 (BOARD/ BAR) RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT UNDER SPECIAL LAWS/ CES/ CSEE NUMBER DATE OF CONFERMENT RELEASE (Continue on separate sheet if necessary) V. Start from your current work) GOV'T SERVICE 30. CIVIL SERVICE ELIGIBILITY 29. Page 2 of 4 .IV. WORK EXPERIENCE (Include private employment.

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

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