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CS FORM 212 (Revised 2003

)

PERSONAL DATA SHEET
Print legibly. Mark appropriate boxes

not older than 6 mos. 3.5 cm. X 4.5 cm (passport size)

I. PERSONAL INFORMATION
1. SURNAME FIRST NAME MIDDLE NAME 2. DATE OF BIRTH 3. PLACE OF BIRTH 4. SEX 5. CIVIL STATUS

with " "

13.

RESIDENTIAL ADDRESS

Male

Female Widowed Separated
ZIP CODE 14. 15. TELEPHONE NO.

Single
Married

PERMANENT ADDRESS

6. CITIZENSHIP 7. HEIGHT (m) 8. WEIGHT (kg) 9. BLOOD TYPE 10. GSIS POLICY NO. 11. PAG-IBIG ID NO. 12. PHILHEALTH NO. 16. 17. 18. 19. 20. ZIP CODE TELEPHONE NO. E-MAIL ADDRESS (if any) CELLPHONE NO. (if any) AGENCY EMPLOYEE NO. TIN

II. FAMILY BACKGROUND
21. NAME OF SPOUSE OCCUPATION EMPLOYER/BUS. NAME BUSINESS ADDRESS TELEPHONE NO. 22. NAME OF CHILD/CHILDREN Date of Birth (mm/dd/yyyy) NAME OF CHILD/CHILDREN Date of Birth (mm/dd/yyyy)

(Continue on separate sheet, if necessary) 23. NAME OF FATHER 25 PARENTS ADDRESS 24.

FULL MAIDEN NAME OF MOTHER

III. EDUCATIONAL BACKGROUND
26 LEVEL Name of School (Write in full) DEGREE / COURSE

(Write in full)

Highest Grade/ Level/ Units Earned (if not graduated)

INCLUSIVE DATES OF ATTENDANCE

From

To

ELEMENTARY SECONDARY VOCATIONAL/ TRADE COURSE TERTIARY GRADUATE STUDIES - Diploma - Master's - Doctorate

NON-DEGREE COURSE* *(course taken aside from Tertiary education but not classified as Graduate Studies) (Continue on separate sheet, if necessary)

5 cm (passport size) tinue on separate sheet. 3.not older than 6 mos. if necessary) ACADEMIC HONORS RECEIVED tinue on separate sheet. if necessary) . X 4.5 cm.

Start from most recent work experience. if necessary) Affix your signature: Date : .) 28. WORK EXPERIENCE (Include private employment. if necessary) V. CIVIL SERVICE ELIGIBILITY 27.IV. INCLUSIVE DATES (mm/dd/yyyy) From To POSITION TITLE (Write in full) DEPARTMENT / AGENCY / OFFICE (Write in full) MONTHLY SALARY (Continue on separate sheet. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEE RATING Date of Examination/ Conferment Place of Examination/ Conferment LICENSE (if applicable) Number (Continue on separate sheet.

LICENSE (if applicable) Date of Release tinue on separate sheet. if necessary) . if necessary) STATUS OF APPOINTMENT tinue on separate sheet.

if necessary) VII. if necessary) VIII. OTHER INFORMATION 31.VI. SPECIAL SKILLS / HOBBIES: 32. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S 29. NAME & ADDRESS OF ORGANIZATION (Write in full) INCLUSIVE DATES (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK From To (Continue on separate sheet. TITLE OF SEMINAR/CONFERENCE/WORKSHOP (Write in full) INCLUSIVE DATES OF ATTENDANCE (mm/dd/yyyy) NUMBER OF HOURS CONDUCTED/ SPONSORED BY (Write in full) From To (Continue on separate sheet. Write in full MEMBERSHIP IN ASSOCIATION/ORGANIZATION Write in full . NON-ACADEMIC DISTINCTIONS / RECOGNITION: 33. TRAINING PROGRAMS/ STUDY/ SCHOLARSHIP GRANTS (Start from the most recent training.) 30.

give reasons. 39. (g) Parent left solo or alone with the responsibility of parenthood due to abandonment of spouse for at least one (1) year. please specify b. decree. please specify YES YES YES 40. Issued at Issued on * Solo Parent as defined in Section 3 of Republic Act No. ordinance or regulations by any court or tribunal? Have you ever been forced to retire/ resign or dropped from employment in the public or private sector? Have you ever been a candidate in a national or local election (except Barangay election)? YES If your answer is 'YES". give date of election and other particulars. please specify c. (h) Parent left solo or alone with the responsibility of parenthood due to unmarried mother/father who has preferred to keep and rear her/his child/children instead of having others care for them or give them up to a welfare institution. and (c) Solo Parents Welfare Act of 2000 (RA 8972)*. Are you ralated by consanguinity or a. 36. (d) Parent left solo or alone with the responsibility of parenthood due to physical and/or mental incapacity of spouse as certified by a public medical practitioner. Have you ever been declared guilty of any administrative offense? YES If your answer is 'YES". correct and complete statement pursuant to the provisions of pertinent laws. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee) NAME ADDRESS 41. Are you differently abled? If your answer is "YES". Within the third degree? (for NATIONAL GOVERNMENT Employees) YES YES affinity to any of the following : appointing authority. (f) Parent left solo or alone with the responsibility of parenthood due to declaration of nullity or annulment of marriage as decreed by a court or by a church as long as he/she is entrusted with the custody of the children. YES If your answer is 'YES". verified by me and to the best of my knowledge and belief is a true. give particulars.and (j) Any family member who assumes the responsibility of head of family as a result of the death. Are you a solo parent? If your answer is "YES". give details of the offense. abandonment. (b) Parent left solo or alone with the responsibility of parenthood due to the death of spouse. Are you a member of any indigenous group? If your answer is "YES". I trust that this information shall rema confidential. please answer the following items: a. Signature Date Accomplished Community Tax Certificate No. I declare under the penalties of perjury that this Personal Data Sheet has been accomplished in good faith. 38. disappearance or prolonged absence of the parents or solo parent. Pursuant to: (a) Indigenous People's Act (RA 8371). or is serving sentence for a criminal conviction for at least one (1) year. Within the fourth degree? (for LOCAL GOVERNMENT Employees) If your answer is 'YES". I also authorize the agency head / authorized representative to verify / validate the contents stated herein. (e) Parent left solo or alone with the responsibility of parenthood due to legal separation or de facto separation from spouse for at least one (1) year as long as he/she is entrusted with the custody of the children. recommending authority. 8972 refers to any individual who falls under any of the following categories: (a) A woman who gives birth as a result of rape and other crimes against chastity even without a final conviction of the offender: Provided that the mother keeps and raises the child. . (b) Magna Carta for Disabled Persons (RA 7277). chief of office/bureau/ department or person who has immediate supervision over you in the Office. Have you ever been convicted of any crime or violation of any law. (c) Parent left solo or alone with the responsibility of parenthood while the spouse is detained. rules and regulations of the Republic the Philippines. give details of the offense. 37. Bureau or Department where you will be appointed? 35 b. (i) Any other person who solely provides parental care and support to a child or children. YES If your answer is 'YES".34.

rules and regulations of the Republic of entative to verify / validate the contents stated herein. I trust that this information shall remain Right Thumbmark . verified by me and to the best of my statement pursuant to the provisions of pertinent laws.NO NO NO NO NO NO NO NO NO TELEPHONE NO. onal Data Sheet has been accomplished in good faith.