PERSONAL DATA SHEET

2. SURNAME
FIRST NAME MIDOlENAME 4. DATE OF BIRTH (mm/ddIyyyy) NAME EXTENSION (e.g. Jr., Sr.)

01/06/1966

5. PLACE OF BIRTH 6. SEX

MANILA

o Male o Single o Married o Annulled

o Female o Widowed o Separated o Others, specify

ZIPCOOE

8. CITIZENSlfP 9. tElGHT (m) 10. WEIGHT (kg) 11. BLOODTYPE 12. GSlS 10 NO.
13. PAG-IBIG 10 NO. E-MAIL ADDRESS (~ any) CEllPHONE NO. (if any)

ZIP CODE

14. PHILHEAL TH NO. 15. SSSNO.

II. FAMILY BACKGROUND

SPOUSE'S SURNAME
FIRST NAME MlDOlENAME OCCUPAnON EMPLOYERIBUS. NAME BUSINESS ADDRESS TELEPHONE NO. NAME OF CHILD (Write ful

name and list aI)

DATE OF BIRTH (mmIddIyyyy)

(ContitJueon sepiflIft sheet If necesuI)'}

FATHER'S SURNAME FIRST NAME MlDOlENAME . MOTHER'S MAlDEN NAME SURNAME FIRST NAME MlOOLENAME

28. LEVEL
NAME OF SCHOOL (Write in full) DEGREE COURSE (Write in full)

YEAR
GRADUATED

HIGHEST GRADEl

lEVEU
UNITS EARNED (if not graduated)

INClUSIVE DATES OF ATIENOANCE

(if graduated)

From

To

ELEMENTARY

SECONDARY

VOCATIONAL I TRADE COURSE

COUEGE

GRADUATE STUDIES

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- -

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- - -

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VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZA TIONIS -. 31. NAME & ADDRESS OF ORGANIZA nON (Write In full) INCLUSIVE DATES (mm/ddJyyyy) From To NUMBER OF HOURS POSITION I NATURE OF WORI

I I I I I

I I I I I

I I I I I

I I I I I

, on sepallte sheet n

_'[~::J:"I~:I;'
32.

u I. l~IITiT:f~.
COURSES

TTiT INCLUSIVE DATES OF ATTENDANCE (mmlddJyyyy) From To NUMBER OF HOURS CONDUCTED/SPONSOREDB (Write in rull)

TITLE OF SEMINARlCONFERENCElWORKSHOP/SHORT (Write in full)

:lM~"l'.
SPECIAL SKILLS I HOBBIES' .. 34 NON-ACADEMIC DISTINCTIONS I RECOGNITION. (Write in rull) 35. ~,~ .,... ~,.. A'''~ ,~ \ :WritA in full\ \ I pN

33.

:
I "VIIU""'" on separate sheet if. CS FORM 212 (Revised 2005), Paj ie30f4

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IV. CIVIL SERVICE ELIGIBILITY

29.
CAREER SERVICE! RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS! CES/ CSEE RATING DATE OF EXAMINATION I CONFERMENT

LICENSE (if allP'icable) PLACE OF EXAMINATION I CONFERMENT NUMBER pATE OF ,RELEASE

I I
I

I
,

I :

I
(Continue on sepaflte sheet if necessaryJ

V. WORK EXPERIENCE (Include private employment. Start from y_ourcurrent work)

30.
INCLUSIVE DATES
SALARY GRADE

_
MONTHLY SAlARY &STEP
1HCRSeIT
(Forma .()(W)

(milVddIyyyy) From To

POsmON TITlE (Write in full)

DEPARTMENT I AGENCY I OFFICE I COMPANY (Write in fuI)

STATUSOF APPOINTMENT

I GOV'T
SERVICE ~es/No)

I I I I I I I I I I I I I I I I I I

I I I I I I I I I I I I I I I I I I

I I I I I I I I I I I I I I I I I I

I I I I I I I I I I I I I I I I I I
(Continue on separate sheet
if neeesSlty)

CS FORM 212 (Revised 20(5), Page 2 of 4

36. fJ.re you related by consanguinity or affinity to any of the following :

a. Within the third degree (for National Government Employees): appointing authority, recommending authority, chief of officelbureau/department or person who has immediate supervision over you in the Office, Bureau or Department where you will be appOinted?

DYES

DNO

If YES, give details:

b.

Within the fourth degree (for Local Government Employees): appointing authority or recommending authority where you will be appointed?

DYES DNO If YES, give details:

37

a. Have you ever been formally charged?

DYES DNO If YES, give details:

b. Have you ever been guilty of any administrative offense?

DYES DNO If YES, give details:

38. Have you ever been convicted of any crime or violation of any law, decree, ordinance or

regulation by any court or tribunal?

DYES DNO If YES, give details:

39. Have you ever been separated from the service in any of the following modes: resignation,

0YES 0 NO
If YES, give details:

retirement, dropped from the rolls, dismissal, termination, end of term, finished contract, AWQ or phased out, in the public or private sector?

40. Have you ever been a candidate in a national or local election (except Barangay election)?

DYES

DNO

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?
b. Are you differently abIed?
C.

DYES DNO If YES, please specify: DYES DNO If YES, please specify: DYES DNO If YES, please specify:

i _

___,.I_
I

Are you a solo parent?

(Person not related

42.REFERENCES

by consanguinity

or affinity to applicant I appointee)

NAME

ADDRESS

TEL.NO.
10 picture taken within the last 6 months 3.5 em. X 4.5 em I (passport size) 1

43. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and

complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines .. I also authorize the agency head I authorized representative to verify I validate the contents stated herein. I trust that this information shall remain confidential.

Computer generated I or xerox C{)py of picture is not acceptable 1

PHOTO

COMMUNITY TAX CERTIFICATE NO.

ISSUED AT rl-------IS-SU-E-D-O-N-(m-~-d-~---)------~I

SIGNATURE

(Sign inside the box)

~------------D-A-T-E-AC-C-O-M-PL-IS-H-ED------------~IL----RI-GH-T-T-HU-M-B-~--K~i~

CS FORM 212 (Revised 2005).Pag~ 4 of4