Service Office

Location:

Philippines

Posted:

November 09, 2016

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Resume:

CS FORM *** (Revised ****)

PERSONAL DATA SHEET

1. CS ID No.

Print legibly. Mark appropriate boxes with " " and use separate sheet if necessary. (to be

I. PERSONAL INFORMATION

2. SURNAME

FIRST NAME

3. NAME EXTENSION

(e.g. Jr., Sr.)

MIDDLE NAME

16. RESIDENTIAL ADDRESS

/ /

4. DATE OF BIRTH (mm/dd/yyyy)

5. PLACE OF BIRTH

Male Female

6. SEX

7. CIVIL STATUS

Widowed ZIP CODE

Single

Married Separat 17. TELEPHONE NO.

Others, specify 18. PERMANENT ADDRESS

Annulled

8. CITIZENSHIP

9. HEIGHT (m)

10. WEIGHT (kg) ZIP CODE

11. BLOOD TYPE 19. TELEPHONE NO.

12. GSIS ID NO. 20. E-MAIL ADDRESS (if any)

13. PAG-IBIG ID NO. 21. CELLPHONE NO. (if any)

14. PHILHEALTH NO. 22. AGENCY EMPLOYEE NO.

15. SSS NO. 23. TIN

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH

FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUS. NAME

BUSINESS ADDRESS

TELEPHONE NO.

(Continue on separate sheet if necessary)

26. FATHER'S SURNAME

FIRST NAME

MIDDLE NAME

27. MOTHER'S MAIDEN NAME

SURNAME

FIRST NAME

MIDDLE NAME (Continue on separate sheet if necessary)

YEAR

GRADUATED

III. EDUCATIONAL BACKGROUND

HIGHEST GRADE/ INCLUSIVE DATES OF

28. NAME OF SCHOOL DEGREE COURSE LEVEL/ ATTENDANCE

LEVEL (Write in UNITS EARNED

(Write in full) full) (if not From To

graduated)

(if

ELEMENTARY

graduated)

SECONDARY /

VOCATIONAL

COLLEGE

TRADE COURSE

GRADUATE STUDIES

(Continue on separate sheet if necessary)

DATA SHEET

(to be filled up by CSC)

DATE OF BIRTH (mm/dd/yyyy)

/ /

(Continue on separate sheet if necessary)

SCHOLARSHIP/

ACADEMIC HONORS

RECEIVED

rate sheet if necessary)

Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY

LICENSE (if applicable)

29. DATE OF

CAREER SERVICE/ RA 1080 (BOARD/ BAR)

RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT

UNDER SPECIAL LAWS/ CES/ CSEE DATE OF

NUMBER

CONFERMENT

RELEASE

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work) GOV'T

SERVICE

POSITION TITLE SALARY GRADE

INCLUSIVE DATES

30. DEPARTMENT / AGENCY / OFFICE / & STEP

MONTHLY STATUS OF

(mm/dd/yyyy) COMPANY INCREMENT

(Write in SALARY (Format "00- APPOINTMENT

(Write in full)

full) 0")

From To

(Yes / No)

/ / / /

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2005), Page 2 of 4

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

INCLUSIVE DATES

31. NAME & ADDRESS OF ORGANIZATION NUMBER OF

POSITION / NATURE OF WORK

(Write in full) HOURS

(mm/dd/yyyy)

From To

/ / / /

(Continue on separate sheet if necessary)

VII. TRAINING PROGRAMS (Start from the most recent training.)

INCLUSIVE DATES OF

ATTENDANCE

32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES NUMBER OF CONDUCTED/ SPONSORED BY

(Write in full) HOURS (Write in full)

(mm/dd/yyyy)

From To

/ / / /

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN

NON-ACADEMIC DISTINCTIONS / RECOGNITION: ASSOCIATION/ORGANIZATION

33. SPECIAL SKILLS / HOBBIES: 34. 35.

(Write in full)

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2005), Page 3 of 4

36. Are you related by consanguinity or affinity to any of the following :

a. Within the third degree (for National Government Employees): YES NO

appointing authority, recommending authority, chief of If YES, give details:

office/bureau/department or person who has immediate supervision over you

in the Office, Bureau or Department where you will be appointed?

b. Within the fourth degree (for Local Government Employees): YES NO

appointing authority or recommending authority where If YES, give details:

you will be appointed?

37 a. Have you ever been formally charged? YES NO

If YES, give details:

YES NO

b. Have you ever been guilty of any administrative offense?

If YES, give details:

38. Have you ever been convicted of any crime or violation of any law, decree, YES NO

ordinance or regulation by any court or tribunal? If YES, give details:

39. Have you ever been separated from the service in any of the following modes: YES NO

resignation, retirement, dropped from the rolls, dismissal, termination, end of

term, finished contract, AWOL or phased out, in the public or private sector? If YES, give details:

40. Have you ever been a candidate in a national or local election (except YES NO

Barangay election)?

If YES, give details:

41. 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 differently abled? YES NO

If YES, please specify:

c. Are you a solo parent? YES NO

If YES, please specify:

42. 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)

Computer generated

43. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a or xerox copy of picture

true, correct and complete statement pursuant to the provisions of pertinent laws, rules and is not acceptable

regulations of the Republic of the Philippines.

I also authorize the agency head / authorized representative to verify / validate the contents

stated herein. I trust that this information shall remain confidential. PHOTO

COMMUNITY TAX CERTIFICATE NO.

ISSUED AT SIGNATURE (Sign inside the box)

/ /

ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

CS FORM 212 (Revised 2005), Page 4 of 4

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