CS Form 212 (Revised 2003)

Not older than 6

months 3.5 x 4.5
cm (passport
size)

 with “ √ “
Print Legibly, Mark Appropriate box
I. PERSONAL INFORMATION
1. SURNAME
FIRST NAME
MIDDLE NAME
2. DATE OF BIRTH 13. RESIDENTIAL
3. PLACE OF BIRTH ADDRESS
4. SEX  Male  Female
 Single  Widower ZIP CODE
5. CIVIL STATUS
 Married  Separated 14. TELEPHONE NO.
6. CITIZENSHIP 15. PERMANENT
7. HEIGHT ADDRESS
8. WEIGHT (kg.)
9. BLOOD TYPE ZIP CODE
10. GSIS POLICY NO. 16. TELEPHONE NO.
11. PAG-IBIG NO. 17. E-MAIL ADDRESS
12. PHIL HEALTH NO. 18. CELLPHONE NO.
19. AGENCY EMPLOYEE NO.
20. TIN
II. FAMILY BACKGROUND
21. NAME OF FATHER 25. NAME OF SPOUSE
22. MOTHER’S OCCUPATION
MAIDEN NAME EMPLOYER/BOSS NAME

23. PARENTS BUSINESS NAME

ADDRESS

24. NAME OF CHILD/CHILDREN Date of Birth (mm/dd/yyyy) NAME OF CHILD/CHILDREN Date of Birth (mm/dd/yyyy)

(Use separate sheet, if necessary)

III. EDUCATIONAL BACKGROUND
INCLUSIVE DATE Highest ACADEMIC
NAME OF SCHOOL DEGREE/COURSE/UNITS OF ATTENDANCE
LEVEL Grade/Level HONORS
(Write in full) (Write in full) Finished RECEIVED
FROM TO
ELEMENTARY DEGREE/COURSE Units Earned
TITLE (if not
SECONDARY (Write in full) graduated)
VOCATIONAL TRADE
SCHOOL
TERTIARY COURSE
(COLLEGE)
GRADUATES STUDIES
- Master’s Degree
- Diploma
- Doctorate
NON DEGREE COURSE
* (course taken aside from Tertiary education but not classified as Graduate Studies)
(Use separate sheet, if necessary)
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/RA 1080 Date of LICENSE (If applicable)
(BOARD/BAR)UNDER SPECIAL Place of Examination
RATING Examination/
Conferment Date of
LAWS/CES/CSE Conferment Number
release

(Use separate sheet, if necessary)

V. SERVICE RECORD
INCLUSIVE DATES POSITION TITLE DEPARTMENT/AGENCY/OFFICE MONTHLY STATUS OF
(mm/dd/yyyy) (Write in full) (Write in full) SALARY APPOINTMENT

(Use separate sheet, if necessary)

Affix your signature:

VI. VOLUNTARY WORK IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION
INCLUSIVES DATES
NAME & ADDRESS OF ORGANIZATION (mm/dd/yyyy)
NUMBER OF
POSITION / NATURE OF WORK
(Write in full) HOURS
From To

(Use separate sheet, if necessary)

VII. TRAINING PROGRAMS / STUDY / SCHOLARSHIP GRANTS (start from the most recent training)
INCLUSIVES DATES
TITLE OF SEMINARS / CONFERENCE / WORKSHOP (mm/dd/yyyy)
NUMBER OF CONDUCTED / SPONSORED BY
(Write in full) HOURS (Write in full)

(Use separate sheet, if necessary)

VIII. OTHER INFORMATION
32. NON-ACADEMIC DISTINCTIONS / RECOGNITION 33. MEMBERSHIP IN ASSOCIATION/
31. SPECIAL SKILLS
(Write in full) ORGANIZATION (Write in full)

(Use separate sheet, if necessary)

34. Are you related by consanguinity or affinity to any of a. Within the third degree?  YES  NO
the following: appointing authority, recommending (for NATIONAL GOVERNMENT Employees)
authority, chief of bureau/ office or person who has b. Within the fourth degree?
immediate supervision over you in the Office, Bureau or (for LOCAL GOVERNMENT Employees)  YES  NO
Department where you will be appointed? If your answer is “YES”, give particulars. __________________________________________________________
35. Have you ever been declared guilty of any  YES  NO
administrative offense? If your answer is “YES”, give details of the offense ________________________________________________________
________________________________________________________________________________________________
36. Have you ever been convicted of any crime or violation  YES  NO
of any law, decree, ordinance or regulations by any court If your answer is “ YES”, give details of the offense _______________________________________________________
or tribunal? ________________________________________________________________________________________________
37. Have you ever been forced to retire/resign or dropped  YES  NO
from employment in the public or private sector? If your answer is “YES”, give reasons. __________________________________________________________________

38. Have you ever been a candidate in a national or local  YES  NO

election (except barangay election)? If your answer is “YES”, give date of election and other particulars . . _________________________________________
________________________________________________________________________________________________
39. Pursuant to (a) Indigenous people’s act (RA 8371) (b) a. Are you a member of any indigenous group?  YES  NO
Magna Carta for Disabled Persons (RA 7277) ; and (c) If your answer is “YES”, please specify. _________________________________________________________
Solo Parents Welfare Act of 2000 (RA 8972)? Please b. Are you differently abled?  YES  NO
answer the following items: If your answer is “YES”, please specify. __________________________________________________________
c. Are you a solo parent?  YES  NO
If your answer is “YES”, please specify. __________________________________________________________
40. REFERENCES (Persons not related by consanguinity or affinity of applicant / appointee)
NAME ADDRESS TELEPHONE NO.

41. I declare under the penalties of perjury that this Personal Date Sheet has been accomplished in good faith, verified by me and to the best of my knowledge and belief 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 remains confidential.

Signature
Date Accomplished
Community Tax Certificate No.
Issued at
Issued on

Right Thumbmark
Solo Parent as defined in Section 3 of Republic Act No. 897 refers to any individual who fall under any of the following categories.
a. A woman who gives birth as a result of rape & other crimes against chastity even without a final conviction of the offender.
Provided that the mother keeps and raises the child.
b. Parent left solo or alone with the responsibility of parenthood due to the death of spouse.
c. Parent left solo or alone with the responsibility of parenthood while the spouse is detained or is serving sentence for a criminal conviction for at least one (1) year.
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.
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.
f. Parent left solo or alone with the responsibility of parenthood due to declaration of nullity or annulment of marriage as decreed by court or by a church as long as he / she is
entrusted with the custody of the children.
g. Parent left solo or alone with the responsibility of parenthood due to abandonment of spouse for at least one (1) year.
h. Parent left solo or alone with the responsibility of parenthood due to to unmarried mother / father who has preferred to keep and rear her / his chilld / children instead of having
others care for them or give them up to a welfare institution.
i. Any other person who solely provides parents care and support to a child or children, and
j. Any family member who assumes the responsibility of head of family as a result of the death, abandonment with the parents or solo parent.

C/:Personnel Forms/CS Form 212/ACPahang/110603