CS FORM 212 (Revised 2003)

PERSONAL DATA SHEET

not older than 6 mos.
3.5 cm. X 4.5 cm
(passport size)

Print legibly. Mark appropriate boxes with " "

I. PERSONAL INFORMATION

1. SURNAME

FIRST NAME

MIDDLE NAME
2. DATE OF BIRTH 13. RESIDENTIAL
3. PLACE OF BIRTH ADDRESS
4. SEX Male Female
5. CIVIL STATUS ZIP CODE
Single Widowed
14. TELEPHONE NO.
Married Separated 15. PERMANENT
ADDRESS
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)

(Continue on separate sheet, if necessary)

23. NAME OF FATHER 24. FULL MAIDEN NAME OF MOTHER

25 PARENTS
ADDRESS
III. EDUCATIONAL BACKGROUND
26 Highest Grade/ INCLUSIVE
Level/ DATES OF ACADEMIC
Name of School
LEVEL DEGREE / COURSE Units Earned ATTENDANCE HONORS
(Write in full)
(if not graduated) RECEIVED
(Write in full)
From To
ELEMENTARY

SECONDARY
VOCATIONAL/

TRADE COURSE
TERTIARY

GRADUATE STUDIES
- Diploma

- Master's

- Doctorate

NON-DEGREE COURSE*
*(course taken aside from Tertiary education but not classified as Graduate Studies)
(Continue on separate sheet, if necessary)
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) Date of Examination/ Place of Examination/ LICENSE (if applicable)
RATING
UNDER SPECIAL LAWS/ CES/ CSEE Conferment Conferment Number Date of Release

(Continue on separate sheet, if necessary)

V. WORK EXPERIENCE (Include private employment. Start from most recent work experience.)
28. INCLUSIVE DATES MONTHLY STATUS OF
DEPARTMENT / AGENCY / OFFICE
(mm/dd/yyyy) POSITION TITLE
(Write SALARY APPOINTMENT
(Write in full)
in full)
From To

(Continue on separate sheet, if necessary)

Affix your signature: Date :

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
29.
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES (mm/dd/yyyy) NUMBER OF
(Write in full) POSITION / NATURE OF WORK
HOURS
From To

(Continue on separate sheet, if necessary)

VII. TRAINING PROGRAMS/ STUDY/ SCHOLARSHIP GRANTS (Start from the most recent training.)
30.
TITLE OF SEMINAR/CONFERENCE/WORKSHOP INCLUSIVE DATES OF ATTENDANCE (mm/dd/yyyy)
NUMBER OF CONDUCTED/ SPONSORED BY
(Write in full) HOURS (Write in full)
From To

(Continue on separate sheet, if necessary)

VIII. OTHER INFORMATION
31. SPECIAL SKILLS / HOBBIES: 32. NON-ACADEMIC DISTINCTIONS / RECOGNITION: 33. MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
Write in full Write in full
 34. Are you ralated by consanguinity or a. Within the third degree? YES NO
affinity to any of the following : (for NATIONAL GOVERNMENT Employees)
appointing authority, recommending
authority, chief of office/bureau/ b. Within the fourth degree? YES NO
department or person who has (for LOCAL GOVERNMENT Employees)
immediate supervision over you in the
Office, Bureau or Department where If your answer is 'YES", give particulars.
you will be appointed?

35 Have you ever been declared guilty of any YES NO

administrative offense? If your answer is 'YES", give details of the offense.

36. Have you ever been convicted of any crime YES NO

or violation of any law, decree, ordinance or
If your answer is 'YES", give details of the offense.
regulations by any court or tribunal?

37. Have you ever been forced to retire/ resign or YES NO

dropped from employment in the public or If your answer is 'YES", give reasons.
private sector?

38. Have you ever been a candidate in a national YES NO

or local election (except Barangay election)? If your answer is 'YES", give date of election and other particulars.

39. Pursuant to: (a) Indigenous People's Act (RA a. Are you a member of any indigenous group? YES NO
8371); (b) Magna Carta for Disabled Persons If your answer is "YES", please specify
(RA 7277); and (c) Solo Parents Welfare Act b. Are you differently abled? YES NO
of 2000 (RA 8972)*, please answer the If your answer is "YES", please specify
following items: 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 ADDRESS TELEPHONE NO.

41. 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.

I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust that this information shall remain
confidential.

Signature

Date Accomplished

Community Tax Certificate No.

Issued at

Issued on Right Thumbmark

* Solo Parent as defined in Section 3 of Republic Act No. 8972 refers to any individual who falls under any of the following categories:
(a) A woman who gives birth as a result of rape and other crimes against chastity even without a final conviction of the offender: Provided that the mother keeps and raises the child;
(b) Parent left solo or alone with the responsibility of parenthood due to the death of spouse;
(c) Parent left solo or alone with the responsibility of parenthood while the spouse is detained, or is serving sentence for a criminal conviction for at least one (1) year;
(d) Parent left solo or alone with the responsibility of parenthood due to physical and/or mental incapacity of spouse as certified by a public medical practitioner;
(e) Parent left solo or alone with the responsibility of parenthood due to legal separation or de facto separation from spouse for at least
one (1) year as long as he/she is entrusted with the custody of the children;
(f) Parent left solo or alone with the responsibility of parenthood due to declaration of nullity or annulment of marriage as decreed by a court
or by a church as long as he/she is entrusted with the custody of the children;
(g) Parent left solo or alone with the responsibility of parenthood due to abandonment of spouse for at least one (1) year;
(h) Parent left solo or alone with the responsibility of parenthood due to unmarried mother/father who has preferred to keep and rear her/his child/children
instead of having others care for them or give them up to a welfare institution;
(i) Any other person who solely provides parental care and support to a child or children;and
(j) Any family member who assumes the responsibility of head of family as a result of the death, abandonment, disappearance or prolonged absence of the parents or solo parent.