CS FORM 212 (Revised 2003)

1. SURNAME
FIRST NAME
MIDDLE NAME
2. DATE OF BIRTH 13. RESIDENTIAL
3. PLACE OF BIRTH ADDRESS
4. SEX
5. CIVIL STATUS ZIP CODE
14. TELEPHONE NO.
15.
6. CITIZENSHIP
7. HEIGHT (m) ZIP CODE
8. WEIGHT (kg) 16. TELEPHONE NO.
9. BLOOD TYPE 17. E-MAIL ADDRESS (if any)
10. GSIS POLICY NO. 18. CELLPHONE NO. (if any)
11. PAG-IBIG ID NO. 19.
AGENCY EMPLOYEE NO.
12. PHILHEALTH NO. 20. TIN
II. FAMILY BACKGROUND
21. NAME OF SPOUSE
OCCUPATION
EMPLOYER/BUS. NAME
BUSINESS ADDRESS
TELEPHONE NO.
22. NAME OF CHILD/CHILDREN Date of Birth (mm/dd/yyyy) NAME OF CHILD/CHILDREN Date of Birth (mm/dd/yyyy)
23. NAME OF FATHER 24.
25 PARENTS
ADDRESS
III. EDUCATIONAL BACKGROUND
26
ELEMENTARY
SECONDARY
VOCATIONAL/
TRADE COURSE
TERTIARY
GRADUATE STUDIES
- Diploma
- Master's
- Doctorate
NON-DEGREE COURSE*
(Continue on separate sheet, if necessary)
Name of School
DEGREE / COURSE
PERSONAL DATA SHEET
I. PERSONAL INFORMATION
ACADEMIC
HONORS
RECEIVED
*(course taken aside from Tertiary education but not classified as Graduate Studies)
LEVEL




not older than 6 mos.
3.5 cm. X 4.5 cm
(passport size)
Male Female
Single
Married
Widowed
Separated
Print legibly. Mark appropriate boxes with " "
FULL MAIDEN NAME OF MOTHER

(Write in full)
Highest Grade/
Level/
Units Earned
(if not graduated)
To
INCLUSIVE
DATES OF
ATTENDANCE
From
PERMANENT
ADDRESS
(Write in full)
(Continue on separate sheet, if necessary)
27.
Number Date of Release
V. WORK EXPERIENCE (Include private employment. Start from most recent work experience.)
28.
MONTHLY
STATUS OF
SALARY APPOINTMENT
To
Affix your signature: Date :
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
UNDER SPECIAL LAWS/ CES/ CSEE
IV. CIVIL SERVICE ELIGIBILITY
LICENSE (if applicable)
DEPARTMENT / AGENCY / OFFICE
(Write in full)
Place of Examination/
Conferment
Date of Examination/
Conferment
RATING
INCLUSIVE DATES
(mm/dd/yyyy)
(Continue on separate sheet, if necessary)
POSITION TITLE
(Write in full)
From
(Continue on separate sheet, if necessary)
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
29.
From To
30.
From To
31. SPECIAL SKILLS / HOBBIES: 32. 33.
(Continue on separate sheet, if necessary)
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES (mm/dd/yyyy)
NUMBER OF
HOURS
POSITION / NATURE OF WORK
VII. TRAINING PROGRAMS/ STUDY/ SCHOLARSHIP GRANTS (Start from the most recent training.)
TITLE OF SEMINAR/CONFERENCE/WORKSHOP
CONDUCTED/ SPONSORED BY
(Write in full)
INCLUSIVE DATES OF ATTENDANCE (mm/dd/yyyy)
MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(Continue on separate sheet, if necessary)
VIII. OTHER INFORMATION
NUMBER OF
HOURS
NON-ACADEMIC DISTINCTIONS / RECOGNITION:
(Write in full)
(Write in full)
Write in full
Write in full
34.
a. Within the third degree? YES NO
(for NATIONAL GOVERNMENT Employees)
b. Within the fourth degree? YES NO
If your answer is 'YES", give particulars.
35 YES NO
36. YES NO
37. YES NO
If your answer is 'YES", give reasons.
38. YES NO
a. Are you a member of any indigenous group? YES NO
If your answer is "YES", please specify
b. Are you differently abled? YES NO
If your answer is "YES", please specify
c. Are you a solo parent? YES NO
If your answer is "YES", please specify
40. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)
NAME
PASTOR JOEL BUSA (PASTOR)
MICHEAL PANGILINAN
Signature
Date Accomplished
Community Tax Certificate No.
Issued at
Issued on
Right Thumbmark
39.
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:
Have you ever been forced to retire/ resign or
dropped from employment in the public or
private sector?
Have you ever been convicted of any crime
or violation of any law, decree, ordinance or
regulations by any court or tribunal?
MAY 5.2014

CCI2O14 35438935
CITY OF MANILA
41.
TAMBUNTING ST. TONDO MANILA
VARGAS ST. TONDO MANILA
I declare under the penalties of perjury that this Personal Data Sheet has been accomplished in good faith, verified by me and to the best of my
knowledge and belief is a true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of
the Philippines.
ADDRESS TELEPHONE NO.
I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust that this information shall remain
confidential.
If your answer is 'YES", give details of the offense.
If your answer is 'YES", give date of election and other particulars.
(for LOCAL GOVERNMENT Employees)
Have you ever been a candidate in a national
or local election (except Barangay election)?
If your answer is 'YES", give details of the offense.
Have you ever been declared guilty of any
administrative offense?
Are you ralated by consanguinity or
affinity to any of the following :
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?