CS Form No. 212 Personal Data Sheet
CS Form No. 212 Personal Data Sheet
CS Form No. 212 Personal Data Sheet
212
Revised 2017
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 birth by naturalization
4. PLACE OF BIRTH If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX
Male Female
17. RESIDENTIAL ADDRESS
6 CIVIL STATUS
Single Married House/Block/Lot No. Street
Widowed Separated
Other/s: Subdivision/Village Barangay
7. HEIGHT (m)
City/Municipality Province
8. WEIGHT (kg) ZIP CODE
MIDDLE NAME
OCCUPATION
EMPLOYER/BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.
24. FATHER'S SURNAME
FIRST NAME NAME EXTENSION (JR., SR)
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. BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE UNITS
YEAR
ACADEMIC
LEVEL EARNED
GRADUATED
HONORS
(Write in full)
(Write in full) (if not graduated) RECEIVED
From To
ELEMENTARY
VOCATIONAL /
SECONDARY
COLLEGE TRADE
COURSE
GRADUATE STUDIES
SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (if applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity
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
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 NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES NO
a. Have you ever been found guilty of any administrative offense? YES NO
35.
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? YES If YES, give details:
NO
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 YES NO
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?
If YES, please specify ID No:
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.
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.