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CSC PDS

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11 views

CSC PDS

Uploaded by

Ariel Bellen
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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? YES NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES NO
If YES, give details:

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

b. Have you been criminally charged before any court? YES 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 YES NO
by any court or tribunal? If YES, give details:
________________________________

37. Have you ever been separated from the service in any of the following modes: resignation, YES NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased If YES, give details:
out (abolition) in the public or private sector? `
38. a. Have you ever been a candidate in a national or local election held within the last year (except YES NO
Barangay election)? If YES, give details:
YES NO
If YES, give details:
39. Have you acquired the status of an immigrant or permanent resident of another country? YES 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? YES NO
If YES, please specify:
b. Are you a person with disability? YES NO
If YES, please specify ID No:
c. Are you a solo parent? YES NO
If YES, please specify ID No:

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

NAME ADDRESS TEL. NO.


ID picture taken
the last 6 mon
JOCEL LANGEO PUROK3, BAGNOS, ALICIA, ISABELA 9069614829 3.5 cm. X 4.5
(passport siz
MARC LUYEN PUROK3, BAGNOS, ALICIA, ISABELA 9157105248 With full and hand
name tag and signa

ROBERT LIMOSIN PUROK3, BAGNOS, ALICIA, ISABELA 9557089261


Computer gener
or photocopied p
Computer gener
42. or photocopied p
I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and is not accepta
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the
Philippines. I authorize the agency head/authorized representative to verify/validate the contents stated herein.
I agree that any misrepresentation made in this document and its attachments shall cause the filing of PHOTO
administrative/criminal case/s against me.

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.: 0250846


Signature (Sign inside the box)

Date/Place of Issuance: 07/03/2023, SANTIAGO CITY


Date Accomplished Right Thumbma

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

Person Administering Oath

CS FORM 212 (Revis


If YES, give details:

If YES, give details:


________________________________

If YES, give details:


________________________________

If YES, give details:


________________________________

If YES, give details:


`

If YES, give details (country):

ID picture taken within


the last 6 months
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten


name tag and signature over
printed name

Computer generated
or photocopied picture
Computer generated
or photocopied picture
is not acceptable

PHOTO

Right Thumbmark

, affiant exhibiting his/her validly issued government ID as indicated above.

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

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