CS Form No.

212

PERSONAL DATA SHEET

Revised 2017

WARNING: Any misrepresentation 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 1. CS ID (Do not fill up. For CSC use
ABBREVIATE. No. only)
I. PERSONAL INFORMATION
2 SURNAME
.
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

3 DATE OF BIRTH
16. CITIZENSHIP
. (mm/dd/yyyy) Filipino Dual Citizenship
by birth by naturalization

4 PLACE OF BIRTH If holder of dual citizenship, Pls. indicate country:

.
please indicate the details.
5 SEX Male Female
.
6 CIVIL STATUS Single Married 17. RESIDENTIAL
ADDRESS
Widowed Separated House/Block/Lot No. Street
Other/s:
Subdivision/Vill Barangay
age
7 HEIGHT (m)
.
City/Municipal Province
ity
8 WEIGHT (kg) ZIP
. CODE
9. BLOOD TYPE 18. PERMANENT
ADDRESS
House/Block/Lot No. Street
10 GSIS ID NO.
.
Subdivision/Vill Barangay
age
11 PAG-IBIG ID NO.
.
City/Municipal Province
ity

12 PHILHEALTH NO. ZIP

. CODE

13 SSS NO. 19. TELEPHONE NO.

.

14. TIN NO. 20. MOBILE NO.

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if

any)
II. FAMILY BACKGROUND
22 SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH
. (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS
NAME
BUSINESS ADDRESS

TELEPHONE NO.

24 FATHER'S SURNAME
.
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

25 MOTHER'S MAIDEN NAME

.
SURNAME

FIRST NAME

MIDDLE NAME (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

SCHOLARSH
26 PERIOD OF HIGHEST LEVEL/
NAME OF BASIC YEAR IP/
. LEVE ATTENDANCE UNITS EARNED
SCHOOL EDUCATION/DEGREE/COURSE GRADUATED ACADEMIC
L (if not graduated)
(Write in full) (Write in full) HONORS
From To RECEIVED

ELEMENTARY

SECONDARY

VOCATIONAL /
TRADE COURSE

CS FORM 212 (Revised 2017),

Page 1 of 4
COLLEGE

GRADUATE STUDIES

(Continue on separate sheet if

necessary)

SIGNATURE DAT
E

CS FORM 212 (Revised 2017),

Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ DATE OF LICENSE (if applicable)
RATING
BAR) UNDER SPECIAL LAWS/ CES/ CSEE EXAMINATIO PLACE OF EXAMINATION / CONFERMENT Date
(If NUMBER
BARANGAY ELIGIBILITY / DRIVER'S Applicable) N/ of
LICENSE CONFERME Validit
NT y

(Continue on separate sheet if

necessary)
V. WORK EXPERIENCE
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Expe rience
sheet.
INCLUSIVE SALARY/ JOB/
28.
PAY GRADE (if GOV'T
DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / MONTH STATUS OF
applicable)& SERVI
(mm/dd/yyyy) (Write in full/Do not COMPANY LY STEP (Format
APPOINTMENT
CE (Y/
abbreviate) (Write in full/Do not abbreviate) SALAR "00-0")/
From To N)
Y INCREMENT

(Continue on separate sheet if

necessary)
SIGNATURE DAT
E
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF INCLUSIVE DATES
29.
ORGANIZATION (mm/dd/yyyy) NUMBER OF POSITION / NATURE OF WORK
HOURS
(Write in full)
Fro To
m

(Continue on separate sheet if

necessary)
VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
(Start from the most recent L&D/training program and include only the relevant L&D/training taken for the last five (5) years for Division Chief/Executive/Managerial positions)

INCLUSIVE DATES Type of LD

30. TITLE OF LEARNING AND DEVELOPMENT OF ATTENDANCE ( CONDUCTED/
NUMBER OF
INTERVENTIONS/TRAINING PROGRAMS (mm/dd/yyyy) HOURS Managerial SPONSORED BY
(Write in full) / (Write in full)
Fro To Supervisor
m y/
Technical/e
tc)

(Continue on separate sheet if

necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / MEMBERSHIP IN
31. SPECIAL SKILLS and HOBBIES 32. RECOGNITION 33. ASSOCIATION/ORGANIZATION
(Write in full) (Write in full)

CS FORM 212 (Revised 2017),

Page 3 of 4
 (Continue on separate sheet if
necessary)

SIGNATU DAT
RE E

CS FORM 212 (Revised 2017),

Page 4 of 4
34. Are you related by consanguinity or affinity to the appointing or recommending
authority, or to the
chief of bureau or office or to the person who has immediate supervision over
you in the Office,
Bureau or Department where you will be YES NO
apppointed, YES NO
a. within the third degree? If YES, give details:
b. within the fourth degree (for Local Government Unit - Career Employees)?

35. a. Have you ever been found guilty of any administrative offense? YES NO
If YES, give details:

b. Have you been criminally charged before any YES NO

court? If YES, give details:
Date Filed:
Status of
Case/s:
36. Have you ever been convicted of any crime or violation of any law, decree, YES NO
ordinance or regulation by any court or tribunal? If YES, give details:

37. Have you ever been separated from the service in any of the following modes: YES NO
resignation, retirement, dropped from the rolls, dismissal, termination, end of If YES, give details:
term, finished contract or phased out (abolition) in the public or private sector?
38. a. Have you ever been a candidate in a national or local election held within the YES NO
last year (except Barangay election)? If YES, give details:
b. Have you resigned from the government service during the three (3)-month YES NO
period before the last election to promote/actively campaign for a national or If YES, give details:
local candidate?
39. Have you acquired the status of an immigrant or permanent resident of another YES NO
country?
If YES, give details (country):

40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled
Persons (RA
7277); and (c) Solo Parents Welfare Act of 2000 (RA 8972), please answer the
following items:
a. Are you a member of any indigenous group? YES NO
If YES, please specify:
b. Are you a person with disability? YES NO
If YES, please specify ID
No:
c. Are you a solo parent? YES NO
If YES, please specify ID
No:

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAM ADDRES TEL. NO.

E S ID picture taken within
the last 6 months
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten

name tag and signature over
printed name

Computer generated
42. or photocopied picture
I declare under oath that I have personally accomplished this Personal Data Sheet which is a is not acceptable
true, correct and complete statement pursuant to the provisions of pertinent laws, rules and
regulations of the Republic of the Philippines. I authorize the agency head/authorized
PHOTO
representative to verify/validate the contents stated herein. I agree that any
misrepresentation made in this document and its attachments shall cause the filing of
administrative/criminal case/s against me.

Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated
CS FORM 212 (Revised 2017),
above. Page 5 of 4
 Person Administering
Oath

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's

License, etc.)
PLEASE INDICATE ID Number and Date of
Issuance
Government Issued ID:
Signature (Sign inside the
box)
ID/License/Passport No.:
Date Accomplished
Date/Place of Issuance:

CS FORM 212 (Revised 2017),

Page 6 of 4