Professional Documents
Culture Documents
212
Revised 2017
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
by birth ✘
4. PLACE OF BIRTH If holder of dual citizenship, Pls. indicate country: naturalization
please indicate the details.
5. SEX
Male Female
17. RESIDENTIAL ADDRESS
6 CIVIL STATUS Single Married
House/Block/Lot No. Street
Widowed Separate
Other/s: d Subdivision/Village Barangay
7. HEIGHT (m)
City/Municipality Province
8. WEIGHT (kg) ZIP CODE
FIRST NAME
MIDDLE NAME
OCCUPATION
EMPLOYER/BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.
FIRST NAME
MIDDLE NAME
SURNAME
FIRST NAME
ELEMENTARY
VOCATIONAL /
SECONDARY
COLLEGE TRADE
COURSE
GRADUATE STUDIES
SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (if applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity
SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
29. NAME & ADDRESS OF ORGANIZATION
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To
SEMINAR-WORKSHOP ON EC'S VULNERABILITY AND RISK ASSESSMENT (VRA) AND NATIONAL ELECTRIFICATION
09/28/2017 09/29/2017 16 MANAGERIAL ADMINISTRATION
EMERGENCY RESTORATION PLANNING (ERP)
THE BALANCED SCORECARD (REGIONAL STRATEGY FORMULATION AND EXECUTION- NATIONAL ELECTRIFICATION
06/20/2016 06/24/2016 40 MANAGERIAL ADMINISTRATION
OPERATIONAL PLANNING
ASSOCIATION OF NURSING SERVICE ADMINISTRATORS
REGULAR IV TRAINING PROGRAM 4/28/2010 4/30/2010 24 TECHNICAL OF THE PHILIPPINES, INC. (ANSAP)
BASIC INTRAVENOUS THERAPY TRAINING 4/28/2010 4/30/2010 24 TECHNICAL DAVAO REGIONAL HOSPITAL
TWO-DAY BASIC JOURNALISM SEMINAR 1/30/2003 1/31/2005 16 TECHNICAL DAVAO DEL NORTE ELECTRIC COOPERATIVE, INC.
TWO-DAY IQA WORKSHOP/SEMINAR 12/11/2003 12/12/2003 16 TECHNICAL DAVAO DEL NORTE ELECTRIC COOPERATIVE, INC.
b. within the fourth degree (for Local Government Unit - Career Employees)? YES
If YES, give details:
________________________________
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 court? YES ✘ NO
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, ordinance or regulation
by any court or tribunal? YES ✘ NO
If YES, give details:
________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation,
YES ✘ NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased If YES, give details:
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 last year (except
YES ✘ NO
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last YES ✘ NO
election to promote/actively campaign for a national or local candidate? If YES, give details:
39. Have you acquired the status of an immigrant or permanent resident of another country?
YES ✘ NO
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:
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a 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 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 PHOTO
administrative/criminal case/s against me.
SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.