Personal Information

Surname: ____________________ First Name: ___________________ Middle Name: __________________ Suffix Name:
_________
Employment Status: _______________________ Fund Source: _____________________ Original Plantilla No.: _________________
Original Appointment Date: _____________ Latest Plantilla Number: __________________ Latest Appointment Date:
______________
Birth Date: __________ Birth Place: _______________________ Sex: _______ Civil Status: ____________ Citizenship:
____________
Assigned Station: ___________________ District: ________________ Plantilla Station: ___________________ District:
____________
Religion: __________________ Ethnicity: __________________ Height (m): _______ Weight (kg): _________ Blood Type:
__________
GSIS ID: __________________ Pag-ibig ID: ___________________ Phil Health ID: __________________ SSS:
__________________
Residential Address: _________________________________________ Zip Code: ___________ Telephone:
____________________
Permanent Address: _________________________________________ Zip Code: ___________ Telephone:
____________________
Email Address: ______________________ Cellphone Number: ______________ Agency Number: ___________ TIN:
______________
Community Tax Number: _____________________ Issued at: _______________________________ Issued on: _________________
Spouse
Surname: ____________________ First Name: ___________________ Middle Name: __________________ Suffix Name:
_________
Occupation: __________________ Employer: _____________ Business Address: ______________ Telephone Number:
___________
Father
Surname: ____________________________ First Name: _________________________ Middle Name:
________________________
Mother’s Maiden Name
Surname: ____________________________ First Name: _________________________ Middle Name:
________________________
Children (from eldest to youngest)
Child Name Birthdate Child Name Birthdate

Civil Service Eligibility

Career Service/ RA 1080 Date of Place of License (if applicable)
(Board/Bar) Under Special Rating Examination/ Examination/Conferment Number Date of Release
Laws/ CES/ CSEE Conferment

Other Information
Special Skills/Hobbies Non-Academic Distinctions/Recognition Membership in Association/Organization
(Write in full) (Write in full)
References (Person not related by consanguinity or affinity to applicant/appointee)
Name Address Contact Number

PDS No. 36 - 41
36. Are you related by consanguinity or affinity to any of the following :

a. Within the third degree (for National Government Employees): YES NO

appointing authority, recommending authority, chief of office/bureau/department or person who If YES, give details:
has immediate supervision over you in the Office, Bureau or Department where you will be _____________________________________
appointed? _____________________________________
_____________________________________

b. Within the fourth degree (for Local Government Employees): YES NO

appointing authority or recommending authority where you will be appointed? If YES, give details:
_____________________________________
_____________________________________
_____________________________________
37 a. Have you ever been formally charged? YES NO
If YES, give details:
________________________________
________________________________
b. Have you ever been guilty of any administrative offense? YES NO
If YES, give details:
________________________________
________________________________
38. Have you ever been convicted of any crime or violation of any law, decree, ordinance or YES NO
regulation by any court or tribunal? If YES, give details:
________________________________
________________________________
39. 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, AWOL or
phased out, in the public or private sector? If YES, give details: ________________
________________________________

40. Have you ever been a candidate in a national or local election (except Barangay election)? YES NO
If YES, give details:
________________________________
________________________________
41. 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 differently abled? YES NO
If YES, please specify: ____________________
c. Are you a solo parent? YES NO
If YES, please specify: ____________________
Teacher’s Load
Level Grade Section Subject Ancillary Day From To Total
(Elem,JHS,SHS) (M/T/W/TH/F 00:00 00:00 min. per
) AM/PM AM/P week
M