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PDS - C4

The document contains a series of questions regarding the applicant's relationships, legal history, and personal status, including inquiries about administrative offenses, criminal charges, and separation from service. It also asks about the applicant's involvement in elections and their status as an immigrant, indigenous person, person with disability, or solo parent. Additionally, it includes a section for references and requires the applicant's declaration of the information's accuracy.

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376 views1 page

PDS - C4

The document contains a series of questions regarding the applicant's relationships, legal history, and personal status, including inquiries about administrative offenses, criminal charges, and separation from service. It also asks about the applicant's involvement in elections and their status as an immigrant, indigenous person, person with disability, or solo parent. Additionally, it includes a section for references and requires the applicant's declaration of the information's accuracy.

Uploaded by

4kr5wnbnvh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details: ________________________________
________________________________
NO

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

b. Have you been criminally charged before any court?


If YES, give details: NO
________________________________
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
or tribunal?
If YES, give details: NO
________________________________

37. 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 or phased out (abolition) in the public or If YES, give details: NO
private sector? ________________________________

38. a. Have you ever been a candidate in a national or local election held within the last year (except Barangay
election)?
If YES, give details: NO
b. Have you resigned from the government service during the three (3)-month period before the last election to
promote/actively campaign for a national or local candidate? If YES, give details: NO
39. Have you acquired the status of an immigrant or permanent resident of another country?

If YES, give details (country):


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

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

NAME ADDRESS TEL. NO.

MARIA ALYSSA BUMATAY LA UNION NATIONAL HIGH SCHOOL 9451490067

GUADA LEINA NEGRILLO BARROZO BARANGAY SEVILLA SFLU 9455236241

RANDOLF F. CARMELO PAGDALAGAN NORTE SFLU 9155122736


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 regu

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: N/A

ID/License/Passport No.: N/A Signature (Sign inside the box)


09922037094
Date/Place of Issuance: N/A 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

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