EMPLOYEE DATA SHEET
Print legibly. Mark appropriate boxes
with "
1. CS ID No.
" and use separate sheet if necessary.
(to be filled up by CSC)
I. PERSONAL INFORMATION
2. SURNAME
FIRST NAME
MIDDLE NAME
16. RESIDENTIAL ADDRESS
4. DATE OF BIRTH (mm/dd/yyyy)
5. PLACE OF BIRTH
Male
6. SEX
7. CIVIL STATUS
Female
Single
Married
Annulled
ZIP CODE
Widowed
Separated
17. TELEPHONE NO.
___________Others, specify18. PERMANENT ADDRESS
8. CITIZENSHIP
9. HEIGHT (m)
10. WEIGHT (kg)
ZIP CODE
11. BLOOD TYPE
19. TELEPHONE NO.
12. GSIS NO.
20. E-MAIL ADDRESS (if any)
13. PAG-IBIG ID NO.
21. CELLPHONE NO. (if any)
14. PHILHEALTH NO.
22. AGENCY EMPLOYEE NO.
15. SSS NO.
23. TIN
II. FAMILY BACKGROUND
24. SPOUSE'S SURNAME
25. NAME OF CHILD (Write full name and list all)
DATE OF BIRTH (mm/dd/yyyy)
N/A
FIRST NAME
MIDDLE NA
OCCUPATION
EMPLOYER/BUS. NAME
BUSINESS ADDRESS
TELEPHONE NO.
FIRST NAME
MIDDLE NAME
SURNAME
FIRST NAME
26. FATHER'S SURNAME
27. MOTHER'S MAIDEN NAME
MIDDLE NAME
III. EDUCATIONAL BACKGROUND
28.
NAME OF SCHOOL
DEGREE COURSE
(Write in full)
LEVEL
YEAR
GRADUATED
(Write in full)
(if graduated)
HIGHEST GRADE/
LEVEL/
UNITS EARNED
(if not
graduated)
INCLUSIVE DATES OF
ATTENDANCE
From
To
SCHOLARSHI
P/ ACADEMIC
HONORS
RECEIVED
ELEMENTARY
VOCATIONAL
SECONDARY /
TRADE
COURSE
COLLEGE
GRADUATE STUDIES
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IV. CIVIL SERVICE ELIGIBILITY
29.
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER
SPECIAL LAWS/ CES/ CSEE
RATING
DATE OF
EXAMINATION /
CONFERMENT
LICENSE (if applicable)
PLACE OF EXAMINATION / CONFERMENT
NUMBER
V. WORK EXPERIENCE (Include private employment. Start from your current work)
30.
INCLUSIVE DATES
(mm/dd/yyyy)
From
To
POSITION TITLE
DEPARTMENT / AGENCY / OFFICE / COMPANY
(Write in full)
(Write in full)
DATE OF
RELEASE
GOV'T
SERVICE
MONTHLY
SALARY
SALARY GRADE
& STEP
INCREMENT
(Format "00-0")
STATUS OF
APPOINTMENT
(Yes /
No)
(Continue on separate sheet if necessary)
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VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
31. NAME & ADDRESS OF ORGANIZATION
(mm/dd/yyyy)
(Write in full)
From
NUMBER OF
HOURS
POSITION / NATURE OF WORK
To
(Continue on separate sheet if necessary)
VII. TRAINING PROGRAMS (Start from 2006 to present)
32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write
in full)
INCLUSIVE DATES OF ATTENDANCE
NUMBER OF
HOURS
(mm/dd/yyyy)
From
CONDUCTED/ SPONSORED BY
(Write in full)
To
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
33.
SPECIAL SKILLS / HOBBIES:
NON-ACADEMIC DISTINCTIONS / RECOGNITION:
34.
(Write in full)
35.
MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(Write in
full)
COMPUTER LITERATE
INTERCOLLEGIATE DEBATING
BSU COLLEGE OF CRIMINAL JUSTICE
EDITORIAL BOARD
LITERARY EDITOR
(Continue on separate sheet if necessary)
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36. Are you related by consanguinity or affinity to any of the following :
a. Within the third degree (for National Government Employees):
appointing authority, recommending authority, chief of office/bureau/department or person who
has immediate supervision over you in the Office, Bureau or Department where you will be
appointed?
b. Within the fourth degree (for Local Government Employees):
appointing authority or recommending authority where you will be appointed?
37 a. Have you ever been formally charged?
YES
NO
If YES, give details:
_____________________________________
_____________________________________
_____________________________________
YES
NO
If YES, give details:
_____________________________________
_____________________________________
_____________________________________
YES
NO
If YES, give details:
________________________________
________________________________
YES
b. Have you ever been guilty of any administrative offense?
NO
If YES, give details:
________________________________
________________________________
38. Have you ever been convicted of any crime or violation of any law, decree, ordinance or
regulation by any court or tribunal?
39. 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, AWOL or
phased out, in the public or private sector?
40. Have you ever been a candidate in a national or local election (except Barangay election)?
YES
NO
If YES, give details:
________________________________
________________________________
YES
NO
If YES, give details:
YES
NO
If YES, give details:
41. 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?
b.
Are you differently abled?
c.
Are you a solo parent?
YES
NO
If YES, please specify: ____________________
YES
NO
If YES, please specify: ____________________
YES
NO
If YES, please specify: ____________________
42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)
NAME
ADDRESS
TEL. NO.
ID picture taken within
the last 6 months
3.5 cm. X 4.5 cm
(passport size)
43. I declare under oath that this Personal Data Sheet has been accomplished by me, and 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 shall remain confidential.
Computer generated
or xerox copy of picture
is not acceptable
PHOTO
COMMUNITY TAX CERTIFICATE NO.
ISSUED AT
SIGNATURE (Sign inside the box)
ISSUED ON (mm/dd/yyyy)
DATE ACCOMPLISHED
RIGHT THUMBMARK
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