CS Form No. ***

Revised ****

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

NAME EXTENSION (JR., SR)

FIRST NAME

MIDDLE NAME

3. DATE OF BIRTH

16. CITIZENSHIP

(mm/dd/yyyy) Filipino Dual Citizenship

by by

birth naturalization

4. PLACE OF BIRTH If holder of dual citizenship, Pls. indicate country:

please indicate the details.

5. SEX Male Female

6 CIVIL STATUS Single Married 17. RESIDENTIAL ADDRESS

Widowed Separate House/Block/Lot No. Street

Other/s: d Subdivision/Village Barangay

7. HEIGHT (m)

City/Municipality Province

8. WEIGHT (kg) ZIP CODE

18. PERMANENT ADDRESS

9. BLOOD TYPE

House/Block/Lot No. Street

10. GSIS ID NO.

Subdivision/Village Barangay

11. PAG-IBIG ID NO.

City/Municipality Province

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)

NAME EXTENSION (JR., SR)

FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME

NAME EXTENSION (JR., SR)

FIRST NAME

MIDDLE NAME

25. MOTHER'S MAIDEN NAME

SURNAME

FIRST NAME

MIDDLE NAME (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL HIGHEST LEVEL/ SCHOLARSHIP/

26. PERIOD OF ATTENDANCE YEAR

LEVEL (Write in BASIC EDUCATION/DEGREE/COURSE UNITS

GRADUATED

ACADEMIC

full) (Write in full) EARNED HONORS

(if not graduated) RECEIVED

From To

ELEMENTARY

SECONDARY

VOCATIONAL /

TRADE

COURSE

COLLEGE

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE

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

IV. CIVIL SERVICE ELIGIBILITY

27. LICENSE (if applicable)

CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER RATING DATE OF

SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT

(If Applicable) NUMBER Date of

BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

Validity

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE

(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experience sheet.

GOV'T

28. INCLUSIVE DATES (mm/dd/ SALARY/ JOB/ PAY SERVICE

yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if

MONTHLY STATUS OF

(Write in full/Do not (Write in SALARY

applicable)& STEP

APPOINTMENT

abbreviate) full/Do not abbreviate) (Format "00-0")/

INCREMENT

From To

(Y/ N)

(Continue on separate sheet if necessary)

SIGNATURE DATE

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

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

INCLUSIVE DATES

29. NAME & ADDRESS OF ORGANIZATION

(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK

From To

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED

INCLUSIVE DATES OF

ATTENDANCE Type of LD

30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ( Managerial/ CONDUCTED/ SPONSORED BY

NUMBER OF HOURS

(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)

Technical/etc)

From To

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMBERSHIP IN ASSOCIATION/ORGANIZATION

31. SPECIAL SKILLS and HOBBIES 32. 33. (Write in

(Write in full) 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 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?

YES

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

If YES, give details:

35. a. Have you ever been found guilty of any administrative offense?

YES NO

If YES, give details:

b. Have you been criminally charged before any court? YES NO

If YES, give details:

Date Filed:

Status of Case/s:

36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation

by any court or tribunal? YES NO

If YES, give details:

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 YES NO

If YES, give details:

out (abolition) in the public or private sector?

38. a. Have you ever been a candidate in a national or local election held within the last year (except

Barangay election)? YES NO

If YES, give details:

b. Have you resigned from the government service during the three (3)-month period before the last YES NO

election to promote/actively campaign for a national or local candidate?

If YES, give details:

39. Have you acquired the status of an immigrant or permanent resident of another country?

YES NO

If YES, give details (country):

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?

YES NO

If YES, please specify:

b. Are you a person with disability?

YES NO

If YES, please specify ID No:

c. Are you a solo parent?

YES NO

If YES, please specify ID No:

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAME ADDRESS TEL. NO.

ID picture taken within

the last 6 months

4.5 cm. X 3.5 cm

(passport size)

Computer generated

or photocopied picture

is not acceptable

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. 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

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