CS FORM 212 (Revised 2005)
PERSONAL DATA SHEET
Print legibly. Mark appropriate boxes q with "P " and use separate sheet if necessary.
1. CS ID No.
(to be filled up by CSC)
I. PERSONAL INFORMATION
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2. SURNAME
FIRST NAME
MIDDLE NAME
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| 3. NAME EXTENSION (e.g. Jr., S
16. RESIDENTIAL ADDRESS
4. DATE OF BIRTH (mm/dd/yyyy)
5. PLACE OF BIRTH
6. SEX
7. CIVIL STATUS
q Single
q Widowed
q Married
q Separated
17. TELEPHONE NO.
q Annulled
q Others, specify ___________
18. PERMANENT ADDRESS
ZIP CODE
8. CITIZENSHIP
9. HEIGHT (m)
10. WEIGHT (kg)
ZIP CODE
11. BLOOD TYPE
19. TELEPHONE NO.
12. GSIS ID 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)
FIRST NAME
MIDDLE NAME
OCCUPATION
EMPLOYER/BUS. NAME
BUSINESS ADDRESS
FIRST NAME
MIDDLE NAME
SURNAME
FIRST NAME
TELEPHONE NO.
(Continue on separate sheet if necessary)
26. FATHER'S SURNAME
27. MOTHER'S MAIDEN NAME
MIDDLE NAME
(Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
28.
LEVEL
ELEMENTARY
YEAR
GRADUATED
NAME OF SCHOOL
(Write in full)
DEGREE COURSE
(Write in full)
(if
graduated)
HIGHEST
GRADE/ LEVEL/
UNITS
EARNED
(if not graduated)
INCLUSIVE DATES OF
ATTENDANCE
From
To
SCHOLARSHI
P/ ACADEMIC
HONORS
RECEIVED
SECONDARY
VOCATIONAL /
COLLEGE
COURSE
TRADE
GRADUATE STUDIES
(Continue on separate sheet if necessary)
Page 1 of 4
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
DATE OF
RELEASE
(Continue on separate sheet if necessary)
V. WORK EXPERIENCE (Include private employment. Start from your current work)
30.
INCLUSIVE DATES
(mm/dd/yyyy)
From
To
GOV'T SERVICE
POSITION TITLE
DEPARTMENT / AGENCY / OFFICE / COMPANY
(Write in full)
(Write in full)
MONTHLY
SALARY
SALARY GRADE
& STEP
INCREMENT
(Format "00-0")
STATUS OF
APPOINTMENT
(Yes / No)
/
(Continue on separate sheet if necessary)
CS FORM 212 (Revised 2005), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
31.
INCLUSIVE DATES
NAME & ADDRESS OF ORGANIZATION
(Write in full)
NUMBER OF
HOURS
(mm/dd/yyyy)
From
POSITION / NATURE OF WORK
To
(Continue on separate sheet if necessary)
VII. TRAINING PROGRAMS (Start from the most recent training.)
INCLUSIVE DATES OF ATTENDANCE
32.
TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write in
full)
NUMBER OF
HOURS
(mm/dd/yyyy)
From
To
CONDUCTED/ SPONSORED BY
(Write in full)
(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)
(Continue on separate sheet if necessary)
CS FORM 212 (Revised 2005), Page 3 of 4
36.
a.
b.
37
Are you related by consanguinity or affinity to any of the following :
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?
Within the fourth degree (for Local Government Employees):
appointing authority or recommending authority where you will be appointed?
If YES, give details:
_____________________________________
_____________________________________
_____________________________________
If YES, give details:
_____________________________________
_____________________________________
_____________________________________
a. Have you ever been formally charged?
If YES, give details:
________________________________
________________________________
b. Have you ever been guilty of any administrative offense?
If YES, give details:
________________________________
________________________________
38.
39.
40.
Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by
any court or tribunal?
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?
If YES, give details:
________________________________
________________________________
If YES, give details:
________________________________
________________________________
Have you ever been a candidate in a national or local election (except Barangay election)?
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?
If YES, please specify: ____________________
b.
Are you differently abled?
c.
Are you a solo parent?
If YES, please specify:
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.
COMMUNITY TAX CERTIFICATE NO.
Computer generated
or xerox copy of picture
is not acceptable
PHOTO
ISSUED AT
SIGNATURE (Sign inside the box)
ISSUED ON (mm/dd/yyyy)
DATE ACCOMPLISHED
RIGHT THUMBMARK
CS FORM 212 (Revised 2005), Page 4 of 4
