CS Form No. 212 Revised 2017
PERSONAL DATA SHEET WARNING: WARNING: Any misreresen!"!i#n m"$e in !%e Pers#n"& Pers#n"& D"!" S%ee! "n$ !%e W#r' Eeriene S%ee! s%"&& "*se !%e +i&in, #+ "$minis!r"!i-erimin"& "$minis!r"!i-erimin"& "se #nerne$. READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.
Print le>i
) 4n3 use sep4r4te s2eet if ne5ess4ry. In3i54te N+A if not 4ppli54
1. CS ID No.
. S!RNAME S!RNAME NAME NAME E%TENSIO E%TENSION N (&R
FIRST NAME MIDDLE NAME . DATE OF "IRT (??+33+yyyy)
1/. CITI0ENSIP
Fi Filipino
Dual Citizenship by
,. PLACE OF "IRT 8. SE SE% % / CI9IL STAT!S STAT!S
Pls. in3i54te
If 2ol3er of 3u4l 5iti6ens2ip'
Male
Female
Single
Married
Widowed
Separated
birth
ple4se in3i54te t2e 3et4ils.
1*. RESIDENTIAL ADDRESS ouse+"lo5:+Lot No.
Other/s:
Su<3i=ision+9ill4>e
*. EI#T EI#T (?) City+Muni5ip4lity . EI#T EI#T (:>)
0IP CODE 1. PERMANENT ADDRESS
-. "LOO "LOOD D T$P T$PE E
ouse+"lo5:+Lot No. 1. #SIS ID NO. NO. Su<3i=ision+9ill4>e 11. 11. PA PA#BI"I# #BI"I# ID ID NO. City+Muni5ip4lity 1. PILEALT PILEALT NO.
0IP CODE
1. SSS NO.
1-. TELEPONE NO.
1,. TIN NO.
. MO"ILE NO.
18. A#ENC$ EMPLO$EE NO.
1. EBMAIL ADDRESS (if 4ny)
. SPO!SE@S SPO!SE@S S!RNAME S!RNAME
[email protected]
. NAME of CILDREN (rite full n4?e 4n3 list 4ll) NAME E%TENSION (&R.' SR)
FIRST NAME MIDDLE MID DLE NAME OCC!PATION EMPLO$ER+"!SINESS NAME "!SINESS ADDRESS TELEPONE NO. ,. FATE FATER@S R@S S!RNA S!RNAME ME
NAME E%TENSION (&R.' SR)
FIRST NAME
MIDDLE NAME 8. MOTER@S MOTER@S MAIDEN MAIDEN NAME NAME S!RNAME FIRST NAME MIDDLE NAME
/.
NAME OF SCOOL LE9EL full)
ELEMENTAR$
"ASIC ED!CATION+DE#REE+CO!RSE (rite in (rite in full)
PERIOD OF ATTENDANCE
Fro?
To
HIGHEST LEVEL/ UNITS EARNED (if not graduated)
MIDDLE NAME 8. MOTER@S MOTER@S MAIDEN MAIDEN NAME NAME S!RNAME FIRST NAME MIDDLE NAME
NAME OF SCOOL
/.
"ASIC ED!CATION+DE#REE+CO!RSE (rite in (rite in full)
LE9EL full)
PERIOD OF ATTENDANCE
Fro?
To
HIGHEST LEVEL/ UNITS EARNED (if not graduated)
ELEMENTAR$
SECONDAR$
COLLE#E
#RAD!ATE ST!DIES
CS
","ins! !%e ers#n
(Do not fill up. For CSC use only)
.' SR)
","ins! !%e ers#n
(Do not fill up. For CSC use only)
.' SR)
by
naturalization
5ountry7
Street "4r4n>4y Pro=in5e
Street "4r4n>4y Pro=in5e
DATE OF "IRT (??+33+yyyy)
YEAR GRADUATED
SCOLARSIP+ ACADEMIC ONORS RECEI9ED
YEAR GRADUATED
SCOLARSIP+ ACADEMIC ONORS RECEI9ED
ORM 1 (Re=ise3 1*)' P4>e 1 of ,
*.
CAREER SER9ICE+ RA 1 ("OARD+ "AR) !NDER SPECIAL LAS+ CES+ CSEE "ARAN#A$ ELI#I"ILIT$ + DRI9ER@S LICENSE
RATIN# (If Appli54
DATE OF E%AMINATION + CONFERMENT
LICENSE (if 4p PLACE OF E%AMINATION + CONFERMENT
N!M"ER
*.
.
CAREER SER9ICE+ RA 1 ("OARD+ "AR) !NDER SPECIAL LAS+ CES+ CSEE "ARAN#A$ ELI#I"ILIT$ + DRI9ER@S LICENSE
INCL!SI9E DATES (??+33+yyyy) Fro?
To
RATIN# (If Appli54
POSITION TITLE
DATE OF E%AMINATION + CONFERMENT
LICENSE (if 4p PLACE OF E%AMINATION + CONFERMENT
DEPARTMENT + A#ENC$ + OFFICE + COMPAN$ (rite in full+Do not 4<
(rite in full+Do not 4<
MONTL$ SALAR$
SALAR$+ &O"+ PA$ #RADE (if 4ppli54
N!M"ER
STAT!S OF APPOINTMENT APPOINTMENT
CS FORM 1 (Re=ise3
pli54
SER9ICE
($+
1*)' P4>e of ,
-. NAME ADDRESS OF OR#ANI0ATION
INCL!SI9E DATES (rite in full) Fro?
. TITLE OF LEARNIN# AND DE9ELOPMENT INTER9ENTIONS+TRAININ# PRO#RAMS (rite in full)
N!M"ER OF O!RS
(??+33+yyyy)
SPECIAL S;ILLS 4n3 O""IES
.
POSI POSITI TIO O
N!M"ER OF O!RS
INCL!SI9E DATES OF ATTENDANCE ATTENDANCE
Fro?
1.
(??+33+yyyy) To
Type of LD ( M4n4>eri4l+ Super=isory+ Te52ni54l+et5)
COND!CTE
To
MEM"E
NONBACADEMIC DISTINCTIONS + RECO#NITION (rite in full)
.
N + NAT!RE OF OR;
D+ SPONSORED "$ (rite in full)
RSIP IN ASSOCIATION+OR#ANI0ATION (rite in full)
CS FORM 212 (Revised 2017), Page 3 of 4
,.
Are you rel4te3
uinity or 4ffinity 4ffinity to t2e 4ppointin> 4ppointin> or re5o??en3in> re5o??en3in> 4ut2ority' 4ut2ority' or to t2e 52ief of reeH
YES
<. it2in t2e fourt2 3e>ree (for Lo54l #o=ern?ent !nit B C4reer E?ployees)H
YES
If $ES' >i=e 3et4ils7 JJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ 8.
4. 4=e you e=er uilty of 4ny 43?inistr4ti=e offenseH
YE YES
O
If $ES' >i=e 3et4ils7
<. 4=e you e3
YE YES
O
If $ES' >i=e 3et4ils7 D4te File37 St4tus of C4se+s7 /.
*.
.
4=e you e=er ul4tion
YE YES
If $ES' >i=e 3et4ils7
4=e you e=er ?o3es7 resi>n4tion' retire?ent' 3roppe3 fro? t2e rolls' 3is?iss4l' ter?in4tion' en3 of ter?' finis2e3 5ontr45t or p24se3 out (4
YE YES
O
If $ES' >i=e 3et4ils7
4. 4=e you e=er 4y ele5tion)H
YE YES
O
If $ES' >i=e 3et4ils7
<. 4=e you resi>ne3 fro? t2e >o=ern?ent ser=i5e 3urin> t2e t2ree ()B?ont2 perio3 n for 4 n4tion4l or lo54l 54n3i34teH -.
O
YES
O
If $ES' >i=e 3et4ils7
4=e you 45uire3 t2e st4tus of 4n i??i>r4nt or per?4nent resi3ent of 4not2er 5ountryH
YE YES
O
If $ES' >i=e 3et4ils (5ountry)7 ,.
4.
Pursu4nt to7 (4) In3i>enous People@s A5t (RA *1)K (<) M4>n4 C4rt4 for Dis4 ite?s7 Are you 4 ?e?enous >roupH >roupH
YES
O
If $ES' ple4se spe5ify7 <.
Are you 4 person it2 it2 3is4
YES
O
If $ES' ple4se spe5ify ID No7 5.
Are you 4 solo p4rentH p4rentH
YES
O
If $ES' ple4se spe5ify ID No7 ,1. REFERENCES (Person not rel4te3 uinity or 4ffinity to 4ppli54nt +4ppointee) NAME
ADDRESS
TEL. NO.
09199786873 09197806317 09487981138 ,.
I 3e5l4re un3er o4t2 t24t I 24=e person4lly 455o?plis2e3 t2is Person4l D4t4 S2eet 2i52 is 4 true' 5orre5t 4n3 5o?plete st4te?ent pursu4nt to t2e pro=isions of pertinent l4s' rules 4n3 re>ul4tions of t2e Repuen5y 2e43+4ut2ori6e3 represent4ti=e to =erify+=4li34te t2e 5ontents st4te3 2erein. I 4>ree t24t 4ny ?isrepresent4tion ?isrepresent4tion ?43e in t2is t2is 3o5u?ent 4n3 its 4tt452?ents 4tt452?ents s24ll 54use t2e filin> of 43?inistr4ti=e+5ri?in4l 43?inistr4ti=e+5ri?in4l 54se+s 4>4inst ?e.
ID picture taen !it"in t"e #a$t #a$t % &ont"$ &ont"$ ' c& * + c& (pa$$port $i,e) -it" fu## and "and!ritten na&e tag and $ignature o.er printed na&e o&puter generated or p"otocopied picture i$ not accepta0#e
POTO
(i.e.P4ssport' #SIS' SSS' PRC' Dri=er@s Li5ense' et5.) o=er o=ern? n?en en ssue ssue PLEASE INDICATE ID Nu?
#o=ern?ent Issue3 ID7 ID+Li5ense+P4ssport No.7 D4te+Pl45e of Issu4n5e7
S!"SCRI"ED AND SORN to
Si>n4ture (Si>n insi3e t2e
Ri>2t T2u?
' 4ffi4nt e2i 2is+2er =4li3ly issue3 >o=ern?ent ID 4s in3i54te3 4
Person A3?inisterin> O4t2 CS FORM 1 (Re=ise3 (Re=ise3 1*)' P4>e ,
of ,
