34.

Are you related by consanguinity or affinity to the appointing or

chief of bureau or office or to the person who has immediate supervision
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 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
Status of Case/s:
36. Have you ever been convicted of any crime or violation of any law, decree, YES ∕ NO
ordinance or regulation by any court or tribunal? If YES, give details:

37. Have you ever been separated from the service in any of the following YES ∕ NO
modes: resignation, retirement, dropped from the rolls, dismissal, If YES, give details:
termination, end of term, finished contract or phased out (abolition) in the
public
Haveoryou
private
eversector?
38. a. been a candidate in a national or local election held within YES ∕ NO
the last year (except Barangay election)? If YES, give details:

b. Have you resigned from the government service during the three (3)- YES ∕ NO
month period before the last election to promote/actively campaign for a If YES, give details:
national or local candidate?
39. Have you acquired the status of an immigrant or permanent resident of YES ∕ NO
another country? 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
a 8972),
Are youplease answer
a member the indigenous
of any following items:
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.

MARK A. AGRIPA Barangay Estanza, Legazpi 9083888680

(Chief Operations Officer- Special Projects) City, Albay
DANIEL KIM SOON S. WEE Barangay Tagas, Daraga, 9511066364
(Operations Officer) Albay

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 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 administrative/criminal case/s against me.

42.

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 LICENSE ID

ID/License/Passport No.: 23-6258265

Signature (Sign inside the box)
Date/Place of Issuance: PRC RAWIS, LEGAZPI CITY, ALBAY
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this 21st day of September, 2023, affiant exhibiting his/her validly issued government ID as indicated above.

Person Administering Oath

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