CS FORM 212 (Revised 2005)
PERSONAL DATA SHEET
Print legibly. Mark appropriate boxes q with "P " and use separate form if necessary.
1. CS ID No.
(to be filled up by CSC)
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
6. SEX
Male
Female
7. CIVIL STATUS
Single
Separated
Married
Widowed
ZIP CODE
17. TELEPHONE NO.
Others specify:
Annuled
________________________
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)
DATE OF BIRTH (mm/dd/yyyy)
FIRST NAME
MIDDLE NAME
OCCUPATION
EMPLOYER/BUS. NAME
BUSINESS ADDRESS
TELEPHONE NO.
(Continue on separate form if necessary)
26. FATHER'S SURNAME
FIRST NAME
MIDDLE NAME
27. MOTHER'S MAIDEN NAME
SURNAME
FIRST NAME
MIDDLE NAME
(Continue on separate form if necessary)
III. EDUCATIONAL BACKGROUND
28.
YEAR
GRADUATED
NAME OF SCHOOL
HIGHEST GRADE/
LEVEL/
UNITS EARNED
(if not graduated)
DEGREE COURSE
(Write in full)
LEVEL
(Write in full)
ELEMENTARY
INCLUSIVE DATES OF
ATTENDANCE
From
To
SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED
(if graduated)
SECONDARY
VOCATIONAL /
COLLEGETRADE COURSE
GRADUATE STUDIES
(Continue on separate form 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 form if necessary)
V. WORK EXPERIENCE (Include private employment. Start from your current work)
30.
INCLUSIVE DATES
(mm/dd/yyyy)
From
To
POSITION TITLE
DEPARTMENT / AGENCY / OFFICE / COMPANY
(Write in full)
(Write in full)
GOV'T
SERVICE
MONTHLY
SALARY
SALARY GRADE
& STEP
INCREMENT
(Format "00-0")
STATUS OF
APPOINTMENT
(Yes / No)
(Continue on separate form if necessary)
CS FORM 212 (Revised 2005), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
31. NAME & ADDRESS OF ORGANIZATION
INCLUSIVE DATES
(Write in full)
(mm/dd/yyyy)
From
NUMBER OF
HOURS
POSITION / NATURE OF WORK
To
(Continue on separate form if necessary)
VII. TRAINING PROGRAMS (Start from the most recent training.)
32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write
in full)
INCLUSIVE DATES OF ATTENDANCE
(mm/dd/yyyy)
From
NUMBER OF
HOURS
CONDUCTED/ SPONSORED BY
(Write in full)
To
(Continue on separate form if necessary)
VIII. OTHER INFORMATION
33.
SPECIAL SKILLS / HOBBIES:
34.
NON-ACADEMIC DISTINCTIONS / RECOGNITION:
(Write in full)
35.
MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(Write in full)
(Continue on separate form if necessary)
CS FORM 212 (Revised 2005), Page 3 of 4
36.
a.
b.
37
Are you related by consanguinity or affinity to any of the following :
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?
Within the fourth degree (for Local Government Employees):
appointing authority or recommending authority where you will be appointed?
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:
________________________________________
_______________________
b. Have you ever been guilty of any administrative offense?
YES
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?
________________________________
YES
NO
If YES, give details:
________________________________
________________________________________
_______________________
________________________________
39.
40.
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?
Have you ever been a candidate in a national or local election (except Barangay election)?
YES
NO
If YES, give details:
__________________________________________________
________________________________
_____________
__ ________________
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?
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)
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.
Computer generated
or xerox copy of picture
is not acceptable
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
