(fixed) CS Form No. 212 revised Personal Data Sheet 2017_mabzicle (1).doc

CS Form No. 212 Revised 2017

PERSONAL DATA SHEET WARNING: Any misrepresentation made in the Persona !ata Sheet and the Wor" #$perien%e Sheet sha %a&se t he 'iin( o' administrative)% %on%erned. R#A! *+# A**AC+#! A**AC+#! G,I!# *- FIING -,* *+# P#RS-NA !A*A !A*A S+##* /P!S #F-R# ACC-PIS+ING *+# P!S F-R.

Print legibly. Tick appropriate boxes (

"and use separate sheet if necessary. Indicate N/A if not applicable.

DO NOT ABBREVIATE.

1. C I! No.

I. P#RS-NA INF-RA*I-N #. $%NA&' $%NA&' I%T NA&' &I!!)' NA&'

*. !AT' + ,I%T-

1. CITI'N-IP

(00/dd/yyyy"

ilipino

.P)AC' + ,I%T-

If holder of dual citi2enship3

4.'5

 CI6I) TAT$

please indicate the details.

&ale

e0ale

ingle

&arried

8ido9ed

eparated

17. %'I!'NTIA) A!!%' House/Block/Lot House/Block/Lot No.

+ther/s:

Subdivision/Village 7.-'I;-T (0" City/Municipality <. 8'I;-T (kg"

IP C+!'

=. ,)++! T>P'

1<. P'%&AN'NT A!!%' House/Block/Lot No.

1?. ;I I! N+.

Subdivision/Village 11. PA;@I,I; I! N+.

City/Municipality

1#. P-I)-'A)T- N+.

IP C+!'

1*.  N+.

1=. T')'P-+N' N+.

1. TIN N+.

#?. &+,I)' N+.

14. A;'NC> '&P)+>'' N+.

#1. '@&AI) A!!%' (if any"

II. FA2I3 1AC4GR-,N! ##. P+$' $%NA&' I%T NA&'

#*. NA&' of C-I)!%'N (8rite full na0e and l NA&' '5T'NI+N (B%.3 %"

&I!!)' NA&' +CC$PATI+N '&P)+>'%/,$IN' NA&' ,$IN' A!!%' T')'P-+N' N+. #. AT-'% $%NA&'

I%T NA&' &I!!)' NA&' #4. &+T-'% &+T-'% &AI!'N &AI!'N NA&' $%NA&'

NA&' '5T'NI+N (B%.3 %"

I%T NA&' &I!!)' NA&'

/Contin&e on se

III. #!,CA*I-NA AC4GR-,N! (8rite in ,AIC '!$CATI+N/!';%''/C+$%' '!$CATI+N/!';%''/C+$%'

NA&' + C-++)

#.

P'%I+! + ATT'N!ANC'

)'6') f u l l"

(8rite in full" ro0

')'&'NTA%> 'C+N!A%>

C+))';'

;%A!$AT' T$!I'

/Contin&e on separate sheet i' ne%essary

SIGNA*,R#

!A*#

To

rimina %ase)s a(ainst the person

(!o not fill up. or CC use only"

NA&' '5T'NI+N (B%.3 %"

!ual Citi2enship by

birth

by

naturali2ation

Pls. indicate country:

Street Barangay Province

Street Barangay Province

ist all"

!AT' + ,I%T- (00/dd/yyyy"

parate sheet i' ne%essary

-I;-'T )'6')/

>'A%

$NIT ;%A!$AT'!

'A%N'!

(if not graduated"

C-+)A%-IP/ ACA!'&IC ACA!'&IC -+N+%

%'C'I6'!

C +%& #1# (%eised #?17"3 Page 1 of 

I5. CI5I S#R5IC# #IGIII*3 #7. #7.

CA%'' CA%''% % '%6I '%6IC' C'// %A 1?< 1?
!AT' +( '5A&INATI+N / C+N'%&'NT

%ATIN;

,A%AN;A> ,A%AN;A> ')I;I,I)IT> / !%I6'% )IC'N'

(If Applicable"

P)AC' + '5A&INATI+N / C+N'%&'NT


5. W-R4 #6P#RI#NC# /In%&de private empoyment. Start 'rom yo&r re%ent or" !es%ription o' d&ties sho&d 8e indi%ated in the atta%hed Wor" #$perien%e sheet. #<.

INC)$I6' !AT'

(00/dd/yyyy" To

(8rite in

(8rite in full/!o not abbreiate"

ro0

A)A%>/ B+,/ PA>

!'PA%T&'NT / A;'NC> / +IC' / C+&PAN>

P+ITI+N TIT)'

full/!o not abbreiate"

&+NT-)> A)A%>

;%A!' (if applicable"D T'P (or0at E??@?E"/

INC%'&'NT


SIGNA*,R#

!A*#

CS F-R 2

)IC'N' (if applicable" N$&,'%

!ate of 6alidity

;+6T '%6IC' TAT$ + APP+INT&'NT

(>/ N"

12 /Revised 20179 Pa(e 2 o' 

5I. 5-,N*AR3 W-R4 -R IN5-5##N* IN CI5IC ) N-N;G-5#RN#N* ) P#-P# ) 5-,N*AR3 -RGANI
(00/dd/yyyy"

ro0

P

N$&,'% + -+$%

To


5II. #ARNING AN! !#5#-P#N* /=! IN*#R5#N*I-NS)*RAINING PR-GRAS A**#N!#! /Start 'rom the most re%ent =!)trainin( pro(ram and in%&de ony the reevant =!)trainin( ta"en 'or the ast 'ive /> years 'or !ivision Chie')#$e%&tive)ana(eria positions

Type of )!

INC)$I6' !AT' +

*?. TIT)' + )'A%NIN; AN! !'6')+P&'NT INT'%6'NTI+N/T%AININ; P%+;%A& (8rite in full"

ATT'N!ANC'

C+N N$&,'% + -+$%

(00/dd/yyyy" ro0

To

( &anagerial/ uperisory/ Technical/etc"


5III. -*+#R INF-RA*I-N *1.

P'CIA) FI)) and -+,,I'

*#. N+N@ACA!'&IC !ITINCTI+N / %'C+;NITI+N

(8rite in full"

**.


SIGNA*,R#

!A*#

+ITI+N / NAT$%' + 8+%F

!$CT'!/ P+N+%'! ,> (8rite in full"

&'&,'%-IP IN A+CIATI+N/+%;ANIATI+N A+CIATI+N/+%;ANIATI+N (8rite

in full"

CS F-R 212 /Revised 20179 Pa(e ? o' 

*. Are you related by consanguinity or affinity to the appointing or reco00ending reco00ending authority3 authority3 or to the chief of bureau or office or to the person 9ho has i00ediate superision oer you in the +ffice3 ,ureau or !epart0ent 9here you 9ill be apppointed3

a. 9ithin the third degreeG degreeG b. 9ithin the fourth degree (for )ocal ;oern0ent $nit @ Career '0ployees"G '0ployees"G

>'

N+

>'

N+

If >'3 gie details: *4. a. -ae you eer been found guilty of any ad0inistratie offenseG offenseG >'

N+

If >'3 gie details: b. -ae you been cri0inally charged before before any courtG >'

N+

If >'3 gie details: !ate iled: tatus of Case/s:

*. -ae you eer been conicted of any cri0e or iolation of any la93 la93 decree3 ordinance or regulation by any court or tribunalG >'

N+

If >'3 gie details:

*7. -ae you eer been separated fro0 the serice in any of the follo9ing 0odes: resignation3 retire0ent3 dropped fro0 the rolls3 dis0issal3 ter0ination3 end of ter03 finished contract or phased out (abolition" in the public or priate sectorG *<. a. -ae you eer been a candidate in a national national or local election held 9ithin the last year (except ,arangay election"G

>'

N+

If >'3 gie details: >'

N+

If >'3 gie details: b. -ae you resigned fro0 the goern0ent serice during the three (*"@0onth period before the last election to pro0ote/actiely ca0paign for a national or local candidateG *=. -ae you acHuired the status of an i00igrant or per0anent resident of another countryG

>'

N+

If >'3 gie details: >'

N+

If >'3 gie details (country":

?. Pursuant to: (a" Indigenous Indigenous Peoples Act (%A <*71" (b" &agna Carta Carta for !isabled Persons (%A 7#77" and (c" olo Parents 8elfare Act of #??? (%A <=7#"3 please ans9er the follo9ing ite0s:

a.

Are you a 0e0b 0e0ber er of of any any indig indigen enous ous gro group upG G

b.

Are you a per person son 9ith 9ith dis disabi abilit lityG yG

c.

>'

N+

If >'3 please specify:

Are Are you you a sol solo o par paren entG tG

>'

N+

If >'3 please specify I! No: >'

N+

If >'3 please specify I! No: 1.

%''%'NC' (Person not related by consanguinity or affinity to applicant /appointee"

NA&'

A!!%'

T'). N+.

I!

8it na0e

#. I declare under oath that I hae personally acco0plished this Personal !ata heet 9hich is a true3 correct and co0plete state0ent pursuant to t he proisions of pertinent la9s3 rules and regulations of the %epublic of the Philippines. I authori2e the agency head / authori2ed representatie to erify erify/a /alid lidate ate the conte contents nts stated stated herei herein. n. I agre agree e that that any any 0isre 0isrepre prese senta ntatio tion n 0ade 0ade in this this docu0ent and its attach0ents shall cause the filing of ad0inistratie/cri0inal case/s against 0e.

;oern0ent Issued I!

(i.e.Passport3 ;I3 3 P%C3 !riers )icense3 etc."

PLESE !N"!C#E !" Nu$ber and "ate o% !ssuance Government Issued ID:

C or

I!/)icense/Passport No.:

ignature (ign inside the box"

!ate/Place of Issuance: !ate Acco0plished

$,C%I,'! $,C%I,'! AN! 8+%N to before 0e this

3 affiant exhibiting his/her alidly is sued goern0ent I!

Person Ad0inistering +ath C +%

picture taken 9ithin the last  0onths *.4 c0. 5 .4 c0 (passport si2e" h full and hand9ritten tag and signature oer printed na0e o0puter generated photocopied picture is not acceptable

P-+T+

%ight Thu0b0ark

as indicated aboe.

& #1# (%eised #?17"3 Page  of 

(fixed) CS Form No. 212 revised Personal Data Sheet 2017_mabzicle (1).doc

Recommend Documents