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    YES NO YES NO: (Person Not Related by Consanguinity or Affinity To Applicant /appointee)

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    John Micheal Valenzuela Agustin
    This document contains a personal data sheet that collects information from an applicant for a government position. It asks about the applicant's relationships within the hiring agency, past administrative or criminal offenses, prior separations from government service, political activities, immigrant status, and references. The applicant is required to provide details for any questions answered "YES" and sign to authorize verification and declare that all information is true under oath, with penalties for misrepresentation.

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    YES NO YES NO: (Person Not Related by Consanguinity or Affinity To Applicant /appointee)

    Uploaded by

    John Micheal Valenzuela Agustin
    107 views1 page
    This document contains a personal data sheet that collects information from an applicant for a government position. It asks about the applicant's relationships within the hiring agency, past administrative or criminal offenses, prior separations from government service, political activities, immigrant status, and references. The applicant is required to provide details for any questions answered "YES" and sign to authorize verification and declare that all information is true under oath, with penalties for misrepresentation.

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    This document contains a personal data sheet that collects information from an applicant for a government position. It asks about the applicant's relationships within the hiring agency, past administrative or criminal offenses, prior separations from government service, political activities, immigrant status, and references. The applicant is required to provide details for any questions answered "YES" and sign to authorize verification and declare that all information is true under oath, with penalties for misrepresentation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    107 views1 page

    YES NO YES NO: (Person Not Related by Consanguinity or Affinity To Applicant /appointee)

    Uploaded by

    John Micheal Valenzuela Agustin
    This document contains a personal data sheet that collects information from an applicant for a government position. It asks about the applicant's relationships within the hiring agency, past administrative or criminal offenses, prior separations from government service, political activities, immigrant status, and references. The applicant is required to provide details for any questions answered "YES" and sign to authorize verification and declare that all information is true under oath, with penalties for misrepresentation.

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    © All Rights Reserved
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    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 NO
    b. within the fourth degree (for Local Government Unit - Career Employees)? YES NO
    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 YES NO
    any court or tribunal? If YES, give details:
    ________________________________
    37. Have you ever been separated from the service in any of the following modes: resignation, YES NO
    retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased 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 YES NO
    Barangay election)? 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 PHOTO
    administrative/criminal case/s against me.

    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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