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Person Not Related by Consanguinity or Affinity To Applicant /appointee

This document contains a personal data sheet for a job application. It requests information about the applicant's personal details, education history, work experience, references, and contains a declaration and oath. The data sheet requests various details to evaluate the applicant's eligibility and suitability for the position.

Uploaded by

Khael Angelo Zheus Jacla
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2K views1 page

Person Not Related by Consanguinity or Affinity To Applicant /appointee

This document contains a personal data sheet for a job application. It requests information about the applicant's personal details, education history, work experience, references, and contains a declaration and oath. The data sheet requests various details to evaluate the applicant's eligibility and suitability for the position.

Uploaded by

Khael Angelo Zheus Jacla
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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34.

Are you related by consanguinity or affinity to the appointing or recommending authority, or to the
chief of bureau or office or to the person who has immediate supervision over you in the Office,
Bureau or Department where you will be apppointed,
a. within the third degree? YES NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES NO
If YES, give details:

35. a. Have you ever been found guilty of any administrative offense? YES NO
If YES, give details:

b. Have you been criminally charged before any court? YES NO


If YES, give details:
Date Filed:
Status of Case/s:
36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation YES NO
by any court or tribunal? If YES, give details:
________________________________

37. 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 or phased If YES, give details:
out (abolition) in the public or private sector? Resignation in Private and Government sector
38. a. Have you ever been a candidate in a national or local election held within the last year (except YES NO
Barangay election)? If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the YES NO
last election to promote/actively campaign for a national or local candidate? If YES, give details:
39. Have you acquired the status of an immigrant or permanent resident of another country? YES NO
If YES, give details (country):

40. 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 a person with disability? YES NO
If YES, please specify ID No:
c. Are you a solo parent? YES NO
If YES, please specify ID No:

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAME ADDRESS TEL. NO.


ID picture taken within
the last 6 months
ENGR. RAFAEL CATBAGAN SAN JUAN, LA UNION 09079719137 3.5 cm. X 4.5 cm
(passport size)
ENGR. ROLANDO NAFIANOG CITY OF SAN FERNANDO, LA UNION 09262318191 With full and handwritten
name tag and signature over
printed name
ENGR. LEONORA F. QUARTE CITY OF SAN FERNANDO, LA UNION 09178843434
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied picture
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable

Philippines. I authorize the agency head/authorized representative to verify/validate the contents stated herein.
I agree that any misrepresentation made in this document and its attachments shall cause the filing of PHOTO
administrative/criminal case/s against me.

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)


PLEASE INDICATE ID Number and Date of Issuance
Government Issued ID: PRC
ID/License/Passport No.: 0129284 Signature (Sign inside the box)

Date/Place of Issuance: 12/03/2013 Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.

Person Administering Oath

CS FORM 212 (Revised 2017), Page 4 of 4

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