CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misinterpretation made in the Personal Data Sheet and the Work Experience Sheet shall cause the filing of administrative/criminal case/s against the person
concerned.
READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.
Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE. 1. CS ID No. (Do not fill up. For CSC use only)

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

6 CIVIL STATUS Single Married 17. RESIDENTIAL ADDRESS

Widowed Separated House/Block/Lot No. Street

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

10. GSIS ID NO.

Subdivision/Village Barangay

11. PAG-IBIG ID NO.

City/Municipality Province
12. PHILHEALTH NO. ZIP CODE

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 20. MOBILE NO.

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any)

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME
OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME

NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

25. MOTHER'S MAIDEN NAME

SURNAME

FIRST NAME

MIDDLE NAME (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE HIGHEST LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
UNITS ACADEMIC
LEVEL (Write in full) EARNED
GRADUATED
HONORS
(Write in full) (if not graduated) RECEIVED
From To

ELEMENTARY

VOCATIONAL
SECONDARY /

TRADE
COURSE
COLLEGE

GRADUATE STUDIES
(Continue on separate sheet if necessary)
SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ LICENSE (if applicable)
RATING DATE OF EXAMINATION /
CSEE BARANGAY ELIGIBILITY / DRIVER'S PLACE OF EXAMINATION / CONFERMENT
(If Applicable) CONFERMENT NUMBER Date of
LICENSE
Validity

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experience sheet.
28. GOV'T SERVICE
INCLUSIVE DATES (mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY SALARY/ JOB/ PAY
GRADE (if applicable)& STATUS OF
(Write in full/Do not (Write in full/Do MONTHLY SALARY STEP (Format "00-0")/ APPOINTMENT
abbreviate) not abbreviate) INCREMENT
From To (Y/ N)

(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 20, 2017
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

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
(Start from the most recent L&D/training program and include only the relevant L&D/training taken for the last five (5) years for Division Chief/Executive/Managerial positions)

INCLUSIVE DATES OF ATTENDANCE Type of LD

30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS CONDUCTED/ SPONSORED BY
(mm/dd/yyyy) NUMBER OF HOURS ( Managerial/ Supervisory/
(Write in full) Technical/etc) (Write in full)

From To

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. NON-ACADEMIC DISTINCTIONS / RECOGNITION (Write in full) 33. (Write in
full)

SINGING N/A N/A

(Continue on separate sheet if necessary)

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
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 any court or
YES NO
tribunal?
If YES, give details: ________________________________
________________________________

37. Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped YES NO
from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in the public or If YES, give details: RESIGNED_______________________________
private sector? ________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except Barangay
YES NO
election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last election to YES NO
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
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten

name tag and signature over
printed name

Computer generated
or photocopied picture
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete is not acceptable
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 administrative/criminal case/s against me. PHOTO

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.

JOSE C. CALIXTRO - MPA

CHIEF ADMINISTRATIVE OFFICER
Person Administering Oath

CS FORM 212 (Revised 2017), Page 4 of 4