CS FORM 212 (Revised 2005

)

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) 5. PLACE OF BIRTH 6. SEX 7. CIVIL STATUS

16. RESIDENTIAL ADDRESS

ZIP CODE Widowed Single  Married  Separated 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.

 Male

ale  Fem

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) SANTOS, THELMA S. Page 1 of 4

XF.HR.005 rev. 1 28 April 2010

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. CIVIL SERVICE ELIGIBILITY 29. WORK EXPERIENCE (Include private employment. INCLUSIVE DATES (mm/dd/yyyy) From / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / To / / / / / / / / / / / / / / / / / / / / (Continue on separate sheet if necessary) POSITION TITLE (Write in full) DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY (Write in SALARY full) SALARY GRADE & STEP INCREMENT (Format "000") STATUS OF APPOINTMENT GOV'T SERVICE (Yes / No) CS FORM 212 (Revised 2005).IV. Page 2 of 4 . Start from your current work) 30.

MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full) (Continue on separate sheet if necessary) SANTOS.VI.HR. (Write in full) 35. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S INCLUSIVE DATES 31. THELMA S.005 rev.) 32. 1 28 April 2010 . Page 3 of 4 XF. 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. OTHER INFORMATION NON-ACADEMIC DISTINCTIONS / RECOGNITION: 33. 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. SPECIAL SKILLS / HOBBIES: 34. CS FORM 212 (Revised 2005). TRAINING PROGRAMS (Start from the most recent training.

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

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