34.

Are you related by consanguinity or affinity to the appointing or recommending authority, or to the
chief of bureau or office or to the person who has immediate supervision over you in the Office,
Bureau or Department where you will be apppointed,
a. within the third degree? No
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details: ________________________________
________________________________

35. a. Have you ever been found guilty of any administrative offense? No
If YES, give details: ________________________________
________________________________

b. Have you been criminally charged before any court? No

If YES, give details: ________________________________
________________________________
Date Filed:
Status of Case/s:
36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court No
or tribunal?
If YES, give details: ________________________________
________________________________

37. Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped No
from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in the public or If YES, give details: ________________________________
private sector? ________________________________ Resignation
38. a. Have you ever been a candidate in a national or local election held within the last year (except Barangay No
election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last election to No
promote/actively campaign for a national or local candidate? If YES, give details:

39. Have you acquired the status of an immigrant or permanent resident of another country? No
If YES, give details (country):

40. 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? No
.
If YES, please specify:
b Are you a person with disability? No
.
If YES, please specify ID No:
c. Are you a solo parent? No
If YES, please specify ID No:

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAME ADDRESS TEL. NO.

Eugene Flor Ulpindo Military Cutoff Rd, Baguio City, Philippines 0999-992-5589

Judith Odanee Magwilang Baguio City, Philippines 0998-284-5789

Jinky Joar Finza Baguio City, Philippines 0908-891-8759

42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulati

PHOTO

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of Issuance
Government Issued ID: PRC ID

ID/License/Passport No.: 0920282

Signature (Sign inside the box)

Date/Place of Issuance: Baguio City, Philippines

June 20, 2022
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.

Person Administering Oath

CS FORM 212 (Revised 2017), Page 4 of 4