Administrative Representative

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. D1. CS ID N (Do not fill up. For CSC use only) I. PERSONAL INFORMATION

2. SURNAME

FIRST NAME

NAME EXTENSION (JR., SR)

MIDDLE NAME

3. DATE OF BIRTH

(mm/dd/yyyy) 16. CITIZENSHIP

4. PLACE OF BIRTH If holder of dual citizenship, Pls. indicate country: 5. SEX

please indicate the details.

6 CIVIL STATUS 17. RESIDENTIAL ADDRES

House/Block/Lot No. Street

Subdivision/Village Barangay

7. HEIGHT (m)

City/Municipality Province

8. WEIGHT (kg) ZIP CODE

9. BLOOD TYPE 18. PERMANENT ADDRES

House/Block/Lot No. Street

10. GSIS ID NO.

Subdivision/Village Barangay

11. PAG-IBIG ID NO.

City/Municipality Province

2. PHILHEALTH NO ZIP CODE

3. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 20. MOBILE NO.

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if an

II. FAMILY BACKGROUND

22 SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all)

DATE OF BIRTH (mm/dd/

yyyy)

FIRST NAME

NAME EXTENSION (JR., SR)

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAM

BUSINESS ADDRESS

TELEPHONE NO.

24.ATHER'S SURNAME

FIRST NAME

NAME EXTENSION (JR., SR)

MIDDLE NAME

25MOTHER'S MAIDEN NAME

SURNAME

FIRST NAME

MIDDLE NAME (Continue on separate sheet if necessary) III. EDUCATIONAL BACKGROUND

26.

LEVEL NAME OF SCHOOL

(Write in full)

BASIC EDUCATION/DEGREE/COURSE

(Write in full)

PERIOD OF

ATTENDANCE

HIGHEST LEVEL/

UNITS EARNED

(if not graduated)

YEAR

GRADUATED

SCHOLARSHIP/

ACADEMIC

HONORS

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

CS Form No. 212

Revised 2017

IV. CIVIL SERVICE ELIGIBILITY

27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER

SPECIAL LAWS/ CES/ CSEE

BARANGAY ELIGIBILITY / DRIVER'S LICENSE

RATING

(If Applicable)

DATE OF

EXAMINATION /

CONFERMENT

PLACE OF EXAMINATION / CONFERMENT

LICENSE (if applicable)

NUMBER Date of

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. 28. INCLUSIVE DATES (mm/

dd/yyyy) POSITION TITLE

(Write in full/Do not abbreviate)

DEPARTMENT / AGENCY / OFFICE / COMPANY

(Write in full/Do not abbreviate)

MONTHLY

SALARY

SALARY/ JOB/ PAY

GRADE (if applicable)&

STEP (Format "00-0")

/ INCREMENT

STATUS OF

APPOINTMENT

GOV'T SERVICE

(Y/ N)

From To

(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 29. NAME & ADDRESS OF ORGANIZATION

(Write in full)

INCLUSIVE DATES

(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 30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS

(Write in full)

INCLUSIVE DATES OF

ATTENDANCE

(mm/dd/yyyy)

NUMBER OF HOURS

Type of LD

( Managerial/

Supervisory/

Technical/etc)

CONDUCTED/ SPONSORED BY

(Write in full)

From To

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

31. SPECIAL SKILLS and HOBBIES 32.

NON-ACADEMIC DISTINCTIONS / RECOGNITION

(Write in full)

33.

MEMBERSHIP IN 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 to the appointing or recommending chief h of i bureau or h office or to the person who has immediate supervision over Bureau or Department ff where you will be apppointed, a. within the third degree?

b. within the fourth degree (for Local Government Unit - Career Employees)? If YES, give details:

35. a. Have you ever been found guilty of any administrative offense? If YES, give details:

b. Have you been criminally charged before any court? If YES, give details:

Date Filed:

tatus 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?

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 out (abolition) in the public or private sector? If YES, give details:

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

If YES, give details:

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?

If YES, give details:

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

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) a. please Are you answer a member the following of any indigenous items: group? If YES, please specify:

b. Are you a person with disability?

If YES, please specify ID No:

c. Are you a solo parent?

If YES, please specify ID No:

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.

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

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

Yes/No Cstat Gender

Yes Single Male

No Married Female

Separated

Widowed

Contact this candidate