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
2. SURNAME | | | | | | | | | | | | | | | | | | | | |
FIRST NAME | | | | | | | | | | | | | | | | | | | | |
MIDDLE NAME | | | | | | | | | | | | | | | | | NAME| EXTENSION
3. | (e.g.
| Jr., Sr.)| N/A
4. DATE OF BIRTH (mm/dd/yyyy) 16. RESIDENTIAL ADDRESS
5. PLACE OF BIRTH
6. SEX Male Female
7. CIVIL STATUS ZIP CODE
17. TELEPHONE NO.
18. PERMANENT ADDRESS
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 / /
TELEPHONE NO. / /
(Continue on separate sheet if necessary) / /
26. FATHER'S SURNAME / /
FIRST NAME / /
MIDDLE NAME / /
27. MOTHER'S MAIDEN NAME / /
SURNAME / /
FIRST NAME / /
MIDDLE NAME (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND YEAR
GRADUATED
HIGHEST GRADE/ INCLUSIVE DATES OF
28. NAME OF SCHOOL DEGREE COURSE SCHOLARSHIP/
LEVEL/ ATTENDANCE
LEVEL (Write in (Write in full) ACADEMIC HONORS
UNITS EARNED
full) From To RECEIVED
(if not graduated)
(if
graduated)
ELEMENTARY
SECONDARY
VOCATIONAL /
TRADE
COLLEGE
COURSE
GRADUATE STUDIES
(Continue on separate sheet if necessary)
Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
29. DATE OF LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
UNDER SPECIAL LAWS/ CES/ CSEE NUMBER DATE OF
CONFERMENT
RELEASE
N/A
(Continue on separate sheet if necessary)
V. WORK EXPERIENCE (Include private employment. Start from your current work) GOV'T
SERVICE
30. INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY SALARY GRADE
(mm/dd/yyyy) MONTHLY & STEP STATUS OF
SALARY INCREMENT APPOINTMENT
(Write in full) (Write in full) (Format "00-0")
From To (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 NUMBER OF
(Write in full) (mm/dd/yyyy) POSITION / NATURE OF WORK
HOURS
From 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 NUMBER OF CONDUCTED/ SPONSORED BY
in full) (mm/dd/yyyy) HOURS (Write in full)
From To
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION: ASSOCIATION/ORGANIZATION
33. SPECIAL SKILLS / HOBBIES: 34. 35.
(Write in full)
(Write in full)
(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):
YES NO
appointing authority, recommending authority, chief of office/bureau/department or person who If YES, give details:
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): YES NO
appointing authority or recommending authority where you will be appointed? If YES, give details:
_____________________________________
_____________________________________
_____________________________________
37 a. Have you ever been formally charged?
YES NO
If YES, give details:
________________________________
________________________________
b. Have you ever been guilty of any administrative offense? YES NO
If YES, give details:
________________________________
________________________________
38. Have you ever been convicted of any crime or violation of any law, decree, ordinance or
YES NO
regulation by any court or tribunal? If YES, give details:
________________________________
________________________________
39. Have you ever been separated from the service in any of the following modes: resignation,
YES NO
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:
Regular Retirement
______________________________
40. Have you ever been a candidate in a national or local election (except Barangay election)? 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? YES NO
If YES, please specify: ____________________
b. Are you differently abled? YES NO
If YES, please specify: ____________________
c. Are you a solo parent? 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)
Computer generated
I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and or xerox copy of picture
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable
Philippines.
I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust
that this information shall remain confidential. PHOTO
COMMUNITY TAX CERTIFICATE NO.
ISSUED AT SIGNATURE (Sign inside the box)
ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK
CS FORM 212 Page 4 of 4
