IV.

CIVIL SERVICE
ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (if applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT Date of
(If Applicable
) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT Validity

(Contiue on separate sheet

ecessary
if n )
n
V. WORK EXPERIENCE
(Include private employment. Start from your recent
tion
work)
of duties d be indicated in the attached Work ence
Descrip
28. INCLUSIVE DATES shoul Experi sheet.
SALARY/ JOB/
PAY GRADE (if GOV'T
(mm/dd/yyyy
) POSITION TITLE DEPARTMENT / NCYAGE / OFFICE / COMPANY
MONTHLY STATUS OF
applicable)& STEP SERVICE
(Write in full/Do not abbreviate
) (Write in full/
Do not abbreviate
) SALARY (Format "00-0")/ APPOINTMENT
(Y/ N)
From To INCREMENT

(Continue on separate sheet

ecessary
if n)

SIGNATUR DAT
E E CS FORM 212 (Revised 2017), Page 2 of 4

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY

ORGANIZATION/S
29. NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
(Write in full) (mm/dd/yyyy) NUMBER OF
HOURS POSITION / NATURE OF WORK
From To

(Continue on separate sheet if necessary)

VII. LEARNING AND INTERVENTIONS/TRAINING PROGRAMS ATTENDED

DEVELOPMENT (L&D) e only the relevant L&D/training taken for the last five (5) years for Division Chief/Executive/Managerial
(Start from the most recent L&D/training program positions)
and includ
TITLE OF LEARNING AND INCLUSIVE DATES OF Type of LD
DEVELOPMENT ATTENDANCE NUMBER OF ( Managerial/
30. HOURS Supervisory/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS (mm/dd/yyyy) Technical/etc) (Write in full)
(Write in full) From To

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES
(Write in full) 33. ASSOCIATION/ORGANIZATION
(Write in full)

(Continue on separate sheet if necessary)

 SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 3 of 4

34. Are you related by consanguinity or affinity YES NO

to the appointing or recommending
YES NO
authority, or to chief of bureau or office or
If YES, give details:
to the person who has immediate
supervision over you in the Bureau or
Department where you will be apppointed,
a. within the third degree?
b. within the fourth degree (for Local
Government Unit - Career Employees)?
35. a. Have you ever been found guilty of any
YES NO
administrative offense?
If YES, give details:

b. Have you been criminally charged YES NO

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

37. Have you ever been separated from the YES NO

service in any of the following modes: If YES, give details:
resignation, retirement, dropped from the
rolls, dismissal, termination, end of term,
finished contract or phased out (abolition)
in the public or private sector?
38. a. Have you ever been a candidate in a YES If NO YES, give details:
national or local election held within the last
year (except Barangay election)? If YES, give details:
YES NO
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?
39. Have you acquired the status of an
YES NO
immigrant or permanent resident of another
If YES, give details (country):
country?

40. Pursuantto: (a) Indigenous People's Act YES

NO
(RA 8371); (b) Magna Carta for Disabled If YES, please specify:
Persons YES
If YES, please NO specify ID No:
(RA 7277); and (c) Solo Parents Welfare
Act of 2000 (RA 8972), please answer the If YES, please specify ID No: YES
items: NO
following a. Are you a member of any
indigenous group?

b. Are you a person with disability?

c. Are you a solo parent?

41. REFERENCES (Person not related by consanguinity or affinity to
applicant /appointee)
NAME ADDRESS TEL. NO.

42.
I declare under oath that I have personally
accomplished this Personal Data Sheet which is
a true, correct and complete statement pursuant
to the provisions of pertinent laws, rules and
regulations of the Republic of the 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 administrative/criminal case/s
against me.
 ID picture taken within the
Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's last 6 months
License, etc.) 3.5 cm. X 4.5 cm
(passport size)
PLEASE INDICATE ID Number and Date of
Issuance With full and handwritten
name tag and signature over
Government Issued ID: printed name

Computer generated or
ID/License/Passport No.: photocopied picture is
not acceptable

Date/Place of Issuance: PHOTO

Right Thumbmark

Person Administering Oath

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

CS FORM 212 (Revised 2017),

Page 4 of 4