CSC Form
CSC Form
CSC Form
212
Revised 2017
I. PERSONAL INFORMATION
2. SURNAME
NAME EXTENSION (JR., SR)
FIRST NAME
MIDDLE NAME
3. DATE OF BIRTH
(mm/dd/yyyy) 09/30/1997 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH MANILA CHINESE GENERAL HOSPITAL If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m)
City/Municipality Province
8. WEIGHT (kg) ZIP CODE
18. PERMANENT ADDRESS
9. BLOOD TYPE
House/Block/Lot No. Street
OCCUPATION N/A
MIDDLE NAME
SURNAME
FIRST NAME
VOCATIONAL /
SECONDARY
COLLEGE TRADE
COURSE
GRADUATE STUDIES
READING N/A
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
YES ✘ NO
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, YES ✘ NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or If YES, give details:
phased 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
YES ✘ NO
(except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
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?
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:
Mrs. Myca M. De Leon Virgen Delas Flores 9232788595 With full and handwritten
name tag and signature over
printed name
Mr.Alexander Marquez Plaridel Bulacan 9122898747
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied picture
is not acceptable
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 PHOTO
filing of administrative/criminal case/s against me.
ID/License/Passport No.: 1775609 (PRC ID) Signature (Sign inside the box)
May 18, 2021
Date/Place of Issuance: 06/19/2019
Date Accomplished Right Thumbmark
SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.