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CS Form 212 Personal Data Sheet

PDS

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Leah Vanessa
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79 views

CS Form 212 Personal Data Sheet

PDS

Uploaded by

Leah Vanessa
Copyright
© © All Rights Reserved
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 5

CS Form 212 (Revised 2005)

PERSONAL DATA SHEET


1 CS ID No.

Print legibly. Mark appropriate with and use separate sheet if necessary.

I. PERSONAL INFORMATION
2. SURNAME
FIRST NAME

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

MIDDLE NAME

4. DATE OF BIRTH (mm/dd/yyyy/)

3. NAME EXTENSION (e. g. jr., Sr.)

16. RESIDENTIAL ADDRESS

5. PLACE OF BIRTH
6. SEX

Male

Female

7. CIVIL STATUS

ZIP CODE

Single
Widowed
Married Separated
Annulled Others, specify ___________

17. TELEPHONE NO.


18. PERMANENT ADDRESS

8. CITIZENSHIP
9. HEIGHT (m)

ZIP CODE

10. WEIGTH (kg)


11. BLOOD TYPE

19. TELEPHONE NO.

12. GSIS ID NO.

20. E-MAIL ADDRESS (if any)

13. PAG-IBIG ID NO.

21. CELLPHONE NO. (if any)

14. PHILHEALTH NO.

22. AGENCY EMPLOYEE NO.

15. SSS NO.

23. TIN

II. FAMILY BACKGROUND


24. SPOUSES SURNAME

25. NAME OF CHILD (Write full name and list all)

DATE OF BIRTH (mm/dd/yyyy)

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FIRST NAME
MIDDLE NAME
OCCUPATION
EMPLOYER/BUS. NAME

BUSINESS ADDRESS
TELEPHONE NO.
(Continue on separate sheet if necessary)

26. FATHERS SURNAME


FIRST NAME
MIDDLE NAME
27. MOTHERS MAIDEN NAME
SURNAME
FIRST NAME

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(Continue on separate sheet if necessary)

MIDDLE NAME

III. EDUCATIONAL BACKGROUND


28.
LEVEL

NAME OF SCHOOL
(Write in full)

DEGREE COURSE
(Write in full)

YEAR
GRADUATED
(if graduated)

HIGHEST GRADE/
LEVEL/
UNITS EARNED
(if not graduated)

ELEMENTARY
SECONDARY
VOCATIONAL/
TRADE COURSE
COLLEGE

GRADUATE STUDIES

(Continue on separate sheet if necessary)

Affix your signature:

INCLUSIVE DATES OF
ATTENDANCE
From

To

SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED

IV. CIVIL SERVICE ELIGIBILITY


29. CAREER SERVICE/RA 1080 (BOARD/BAR)
UNDER SPECIAL LAWS/CES/CSEE

RATING

DATE OF
EXAMINATION/
CONFERMENT

LICENSE (if applicable)


PLACE OF EXAMINATION/ CONFERMENT

NUMBER

DATE OF
RELEASE

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work)
30. INCLUSIVES DATES
(mm/dd/yyyy)
From

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To

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POSITION TITLE
(Write in full)

DEPARTMENT/AGENCY/OFFICE/COMPANY
(Write in full)

MONTHLY
SALARY

SALARY GRADE
& STEP
INCREMENT
(Format 00-0)

STATUS OF
APPOINTMENT

GOVT
SERVICE
(Yes / No)

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(Continue on separate sheet if necessary)
CS FORM 212 (Revised 2005), Page 2 of 4

Affix your signature:


VI. Voluntary Work or Involvement in Civic / Non-government / People / Voluntary / Organization
31.

INCLUSIVE DATES

NAME & ADDRESS OF ORGANIZATION

(mm/dd/yyyy)

(Write in full)

From

To

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

NUMBER
OF HOURS

POSITION / NATURE OF WORK

NUMBER
OF HOURS

CONDUCTED / SPONSORED BY
(Write in full)

(Continue on separate sheet if necessary)

VII. TRAINING PROGRAMS (Start from the most recent training.)


32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES

INCLUSIVE DATES OF ATTENDANCE


(mm/dd/yyyy)

(Write in full)

From

To

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(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


33.

SPECIAL SKILLS/HOBBIES

34.

NON-ACADEMIC DISTINCTIONS/RECOGNITION
(Write in full)

35.

MEMBER IN ASSOCIATION/ORGANIZATION
(Write in full)

(Continue on separate sheet if necessary)


CS FORM 212 (Revised 2005), Page 3 of 4

Affix your signature:


36. Are you related by consanguinity to any of the following

YES

a. Within the third degree (for National Government Employee):


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

NO

If YES, give details

___________________________________________________
___________________________________________________
___________________________________________________
YES

NO
If YES, give details

b. Within the fourth degree (for Local Government Employee):


appointing authority or recommending authority where you will be appointed

___________________________________________________
___________________________________________________
___________________________________________________

37. a. Have you ever been formally charge?


YES
NO
If YES, give details

___________________________________________________
___________________________________________________
___________________________________________________
YES
NO
If YES, give details

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

___________________________________________________
___________________________________________________
___________________________________________________
38. Have you ever been convicted of any crime or violation of any law, degree, ordinance or
Regulation by any court or tribunal?

YES
NO
If YES, give details

___________________________________________________
___________________________________________________
___________________________________________________
39. Have you ever been separated from the service in any of the following modes, resignation, retirement,
Dropped from the rolls, dismissal, termination, end of term, finished contract, AWOL 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)?

YES
NO
If YES, give details

___________________________________________________
___________________________________________________
___________________________________________________
YES
NO
If YES, give details

___________________________________________________
___________________________________________________
41. Pursuant to: (a) Indigenous Peoples 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:

YES
NO
If YES, give details

a. Are you a member of any indigenous group?

___________________________________________________
___________________________________________________

b. Are you differently abled?

YES
NO
If YES, give details

___________________________________________________
___________________________________________________

c. Are you a solo parent?

YES
NO
If YES, give details

___________________________________________________
___________________________________________________
42. REFERENCES (Persons not related by consanguinity or affinity to applicant / appointee)
NAME

ADDRESS

TEL. NO.

PHOTO
ID picture taken within the last 6
months 3.5 cm. x 4.5 cm
(passport size)

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/authorized representative to verify / validate the contents stated herein. I trust that this
information shall remain confidential.

Computer generated
or xerox copy of picture
is not acceptable

COMMUNITY TAX CERTIFICATE NO.

ISSUED AT

SIGNATURE (Sign inside the box)

ISSUED ON (mm/dd/yyyy)

DATE ACCOMPLISHED

RIGHT THUMBMARK
CS FORM 212 (Revised 2005), Page 4 of 4

CS Form 212 w sign below (revised 2005)/Personnel Form/ACPahang09262006

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