CS FORM 212 (Revised 2005)
PERSONAL DATA SHEET
Print legibly. Mark appropriate boxes
with "
1. CS ID No.
" and use separate sheet if necessary.
I. PERSONAL INFORMATION
2. SURNAME
FIRST NAME
3. NAME EXTEN
MIDDLE NAME
16. RESIDENTIAL ADDRESS
4. DATE OF BIRTH (mm/dd/yyyy)
5. PLACE OF BIRTH
Male
6. SEX
7. CIVIL STATUS
Fem ale
Single
Widowed
Married
Separated
Annulled
___________Others, specify
ZIP CODE
17. TELEPHONE NO.
18. PERMANENT ADDRESS
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)
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
III. EDUCATIONAL BACKGROUND
(Continue
YEAR
GRADUATED
YEAR
GRADUATED
28.
NAME OF SCHOOL
LEVEL
(Write in full)
DEGREE COURSE
(Write in full)
(if
graduated)
ELEMENTARY
SECONDARY
VOCATIONAL /
TRADE
COURSE
COLLEGE
GRADUATE STUDIES
(Continue on separate sheet if necessary)
HIGHEST GRADE/ LEVEL/
UNITS EARNED
(if not graduated)
DATA SHEET
(to be filled up by CSC)
3. NAME EXTENSION (e.g. Jr., Sr.)
25. NAME OF CHILD (Write full name and list all)
(Continue on separate sheet if necessary)
DATE OF BIRTH (mm/dd/yyyy)
INCLUSIVE DATES OF ATTENDANCE
From
To
SCHOLARSHIP/ ACADEMIC
HONORS RECEIVED
arate sheet if necessary)
Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
29.
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL
LAWS/ CES/ CSEE
RATING
DATE OF
EXAMINATION /
CONFERMENT
LICENSE (if applicable)
PLACE OF EXAMINATION / CONFERMENT
NUMBER
DATE OF
RELEASE
(Continue on separate sheet if necessary)
V. WORK EXPERIENCE (Include private employment. Start from your current work)
GOV'T SERVICE
30.
INCLUSIVE DATES (mm/dd/yyyy) POSITION TITLE
From
DEPARTMENT / AGENCY / OFFICE / COMPANY
(Write in full)
(Write in full)
To
MONTHLY SALARY
SALARY GRADE &
STEP INCREMENT
(Format "00-0")
STATUS OF
APPOINTMENT
(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 ORGANIZATION/S
INCLUSIVE DATES
31.
NAME & ADDRESS OF ORGANIZATION
NUMBER OF
HOURS
(mm/dd/yyyy)
(Write in full)
From
POSITION / NATURE OF WORK
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 (Write in full)
NUMBER OF
HOURS
(mm/dd/yyyy)
From
CONDUCTED/ SPONSORED BY
(Write in full)
To
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
33.
SPECIAL SKILLS / HOBBIES:
34.
NON-ACADEMIC DISTINCTIONS / RECOGNITION:
(Write in full)
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
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):
appointing authority,
recommending authority, chief of 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):
appointing authority or
recommending authority where you will be appointed?
37 a. Have you ever been formally charged?
YES
NO
If YES, give details:
___________________________
___________________________
___________________________
YES
NO
If YES, give details:
___________________________
___________________________
___________________________
YES
NO
If YES, give details: ___________
___________________________
YES
b. Have you ever been guilty of any administrative offense?
NO
If YES, give details: ___________
___________________________
38. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal?
39. 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, AWOL or phased out, in the public or private sector?
YES
NO
If YES, give details: ___________
___________________________
YES
NO
If YES, give details:
___________________________
___________________________
40. Have you ever been a candidate in a national or local election (except Barangay election)?
YES
NO
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?
b.
Are you differently abled?
c.
Are you a solo parent?
YES
NO
If YES, please specify: ________
YES
NO
If YES, please specify: ________
YES
NO
If YES, please specify: ________
42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)
NAME
ADDRESS
TEL. NO.
43. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and complete statement pursuant to the
provisions of pertinent laws, rules and 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.
COMMUNITY TAX CERTIFICATE NO.
ISSUED AT
SIGNATURE (Sign inside the box)
ISSUED ON (mm/dd/yyyy)
DATE ACCOMPLISHED
CS FOR
______________________
______________________
______________________
______________________
______________________
______________________
________________________________
_________________
________________________________
_________________
________________________________
_________________
_________________
_________________
________________________________
_________________
ify: ____________________
ify: ____________________
ify: ____________________
ID picture taken within
the last 6 months
3.5 cm. X 4.5 cm
(passport size)
Computer generated
or xerox copy of picture
is not acceptable
PHOTO
RIGHT THUMBMARK
CS FORM 212 (Revised 2005), Page 4 of 4
AWARDS AND CITATIONS
44.
DATE GIVEN
AWARDS RECEIVED
GIVEN BY
(Continue on separate sheet if necessary)
OFFICER OF PROFESSIONAL, CIVIC, RELIGIOUS AND CULTURAL ORGANIZATION
45.
DATES ACTIVE
POSITION
From
NAME OF GROUP/ ORGANIZATION
To
(Continue on separate sheet if necessary)
CHAIRMANSHIP OR MEMBERSHIP IN ANY OF THE FOLOWING COMMITTEES
1. Bids and Award
Committee - incl TWG
2.
Safety Committee
-Biosafety and
Biosecurity,
Chemical Safety, Fire
Safety, Patient Safety
3. Communication and
Engagement Officer (CEO)
46.
6.
7.
8.
Grievance Committee
Human Resource
Development Committee (HRDC)
Infection Control Committee
12.
Internal Quality Audit
13.
Inventory Committee
14. Patients Assistance and Complaints Unit
(PACU)
15.
9.
Inspection and Acceptance
Committee
4. Continous Quality
Improvement (CQI)
10.
Institutional Aminal Care
5. Gender and
Development
Committee
11.
Institutional Review Board
COMMITTEE NUMBER
18. Research and
Innovation Office (RIO)
Process Team
16. Program on Awards and Incentives for
Service Excellence (PRAISE)
17.
QA Office
-CQI, IQA, Process Team,
Team, Promotions
Quality Circle/
19. Selection and
Promotion Board (SPB)
20.
Surveillance Unit
21. Therapeutics
Committee
22. Training and
Technology Committee (TTRC)
23.
NAME OF INSTITUTE
Othesr to be specified
______________________
INCLUSIVE DATE
RESEARCH INVOLVEMENT
47.
RESEARCH TITILE
INVOLVEMENT
(Continue on separate sheet if necessary)
PUBLICATIONS (Author/Co-Author)
48.
TITLE OF PUBLICATIONS
JOURNAL TITLE
DATE OF PUBLICATION
(Continue on separate sheet if necessary)
TRAINOR
49.
INCLUSIVE DATE
COURSE TITLE
FROM
(Continue on separate sheet if necessary)
CONDUCTED/ ORGANIZED BY
TO
