CS Form No.

212
Revised 2017
PERSONAL DATA SHEET
WARNING: Any misrepresentation made in the Personal Data Sheet and the Work Experience Sheet shall cause the filing of administrative/criminal case/s against the person
concerned.
READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.
Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE. 1. CS ID No. (Do not fill up. For CSC use only)
I. PERSONAL INFORMATION
2. SURNAME

FIRST NAME

MIDDLE NAME

3. DATE OF BIRTH
(mm/dd/yyyy) 9/7/1968 16. CITIZENSHIP

4. PLACE OF BIRTH LOBO, BATANGAS If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX

6 CIVIL STATUS 17. RESIDENTIAL ADDRESS

7. HEIGHT (m)

8. WEIGHT (kg) ZIP CODE

9. BLOOD TYPE 18. PERMANENT ADDRESS

10. GSIS ID NO.

11. PAG-IBIG ID NO.

12. PHILHEALTH NO. ZIP CODE

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 20. MOBILE NO.

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any)

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.
24. FATHER'S SURNAME
FIRST NAME
MIDDLE NAME
25. MOTHER'S MAIDEN NAME
SURNAME
FIRST NAME
MIDDLE NAME (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE LEVEL/ YEAR SCHOLARSHIP/
LEVEL (Write in full) UNITS GRADUATED ACADEMIC HONORS
(Write in full) EARNED RECEIVED
From To (if not graduated)

ELEMENTARY

SECONDARY /
VOCATIONAL

TRADE COURSE
SKILLS

INTERESTS

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 1 of 4
 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?

✘
b. within the fourth degree (for Local Government Unit - Career Employees)?

✘
If YES, give details:
________________________________
N/A
________________________________
35. a. Have you ever been found guilty of any administrative offense?
✘

If YES, give details:

________________________________
N/A
________________________________
b. Have you been criminally charged before any court? ✘
If YES, give details:
________________________________
Date Filed: N/A
________________________________
Status of Case/s: N/A

36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation
by any court or tribunal? ✘

If YES, give details:

________________________________
N/A
________________________________
37. 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 or phased ✘

out (abolition) in the public or private sector? If YES, give details:

________________________________
N/A
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? ✘

If YES, give details: N/A

b. Have you resigned from the government service during the three (3)-month period before the last
election to promote/actively campaign for a national or local candidate? If YES, give details: ✘
N/A
39. Have you acquired the status of an immigrant or permanent resident of another country?
✘
If YES, give details (country):
N/A
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?
If YES, please specify: ✘
N/A
b. Are you a person with disability? ✘
If YES, please specify ID No: N/A
c. Are you a solo parent?
✘
If YES, please specify ID No: N/A

41. 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)

With full and handwritten

name tag and signature over
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and printed name
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Computer generated
Philippines. I authorize the agency head/authorized representative to verify/validate the contents stated herein. or photocopied picture
I agree that any misrepresentation made in this document and its attachments shall cause the filing of is not acceptable
administrative/criminal case/s against me. PHOTO

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

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