CS Form No. 212 Revised 2017
PERSONAL DATA SHEET WARNING: WARNING: Any misinte!et"ti#n m"$e in t%e Pes#n"& D"t" S%eet "n$ t%e W#' E!eiene S%eet s%"&& "*se t%e +i&in, #+ "$minist"ti-eimin"& "ses #nene$. READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.
Print le;i7ly. Ti08 #ppropri#te #ppropri#t e 7oes (
) #n% use sep#r#te s/eet if ne0ess#ry. In%i0#te NA if not #ppli0#7le.
1. CS ID No.
. S!RNAME S!RNAME FIRST NAME MIDDLE NAME &. DATE OF $IRT(==%%yyyy)
1*. CITI,ENS-IP
Fi Filipino
Dual Citizenship by
'. PLACE OF OF $IRT$IRT3. SE SE4 4 * CI5IL STAT!S STAT!S
Pls. in%i0#te
If /ol%er of %u#l 0iti"ens/ip
Male
Female
Single
Married
Widowed
Separated
birth
ple#se in%i0#te t/e %et#ils.
1+. RESIDENTIAL ADDRESS
-ouse$lo08Lot No.
Other/s:
Su7%i:ision5ill#;e
+. -EI<-T -EI<-T (=) CityMuni0ip#lity 6. >EI<-T >EI<-T (8;)
,IP CODE 16. PERMANENT ADDRESS
. $LOO $LOOD D T?P T?PE E
-ouse$lo08Lot No.
1@.
Su7%i:ision5ill#;e
11. 11. PA PA<I$I< <I$I< ID ID NO.
CityMuni0ip#lity
1. P-IL-EALTP-IL-EALT- NO.
,IP CODE
1&. SSS NO.
1. TELEP-ONE NO.
1'. TIN NO.
@. MO$ILE NO.
13. A
1. EMAIL ADDRESS (if #ny)
. SPO!SEBS SPO!SEBS S!RNAME S!RNAME
[email protected]
&.NAME of C-ILDREN (>rite full n#=e #n% list #ll)
FIRST NAME MIDDLE MID DLE NAME OCC!PATION EMPLO?ER$!SINESS NAME $!SINESS ADDRESS TELEP-ONE NO. '. FAT-E FAT-ERBS RBS S!RNA S!RNAME ME FIRST NAME MIDDLE NAME 3. MOT-ERBS MOT-ERBS MAIDEN MAIDEN NAME NAME S!RNAME FIRST NAME MIDDLE NAME
*.
NAME OF SC-OOL LE5EL
$ASIC ED!CATIONDE
rite in (>rite in full)
PERIOD OF ATTENDANCE
HIGHEST LEVEL/ UNITS EARNED
Fro=
To
no !ra #a e
ELEMENTAR?
SECONDAR?
COLLE
A CS
","inst t%e !es#n
(Do not fill up. For CSC use only)
by
naturalization
0ountry2
Street
#unl#r#n $#r#n;#y NCR Pro:in0e
Street 9#unl#r#n $#r#n;#y NCR Pro:in0e
om
DATE OF $IRT- (==%%yy)
%EAR GRADUATED
SC-OLARS-IP ACADEMIC -ONORS
RECEI5ED
pril 1@1+ ORM 1 (Re:ise% @1+) P#;e 1 of '
+.
6.
CAREER SER5ICE RA 1@6@ ($OARD $AR) !NDER SPECIAL LA>S CES CSEE $ARAN
INCL!SI5E DATES (==%%yyyy) Fro=
To
RATIN< (If Appli0#7le)
POSITION TITLE
DATE OF E4AMINATION CONFERMENT
LICENSE (if #p PLACE OF E4AMINATION CONFERMENT
DEPARTMENT Arite in fullDo not #77re:i#te)
(>rite in fullDo not #77re:i#te)
MONT-L? SALAR?
SALAR? O$ PA?
N!M$ER
STAT!S OF APPOINTMENT APPOINTMENT
M#y ' @1+ CS FORM 1 (Re:ise%
pli0#7le) D#te of 5#li%ity
SER5ICE
(?
1+) P#;e of '
. NAME G ADDRESS OF OR
INCL!SI5E DATES (>rite in full) Fro=
&@. TITLE OF LEARNIN< AND DE5ELOPMENT INTER5ENTIONSTRAININ< PROrite in full)
(==%%yyyy) To
INCL!SI5E DATES OF ATTENDANCE ATTENDANCE N!M$ER OF -O!RS
(==%%yyyy) Fro=
To
POSI POSITI TIO O
N!M$ER OF -O!RS
Type of LD ( M#n#;eri#l Super:isory Te0/ni0#let0)
COND!CTE
&1.
SPECIAL S9ILLS #n% -O$$IES
&.
MEM$E
NONACADEMIC DISTINCTIONS RECOrite in full)
&&.
N NAT!RE OF >OR9
D SPONSORED $? (>rite in full)
RS-IP IN ASSOCIATIONORrite in full)
M#y ' @1+ CS FORM 212 (Revised 2017), Page 3 of 4
&'.
Are you rel#te% 7y 0ons#n;uinity or #ffinity #ffinity to t/e #ppointin; #ppointin; or re0o==en%in; re0o==en%in; #ut/ority #ut/ority or to t/e 0/ief of 7ure#u or offi0e or to t/e person /o /#s i==e%i#te super:ision o:er you in t/e Offi0e $ure#u or Dep#rt=ent /ere you ill 7e #pppointe% #. it/in t/e t/ir% %e;ree
YES
O
7. it/in t/e fourt/ %e;ree (for Lo0#l
YES
O
If ?ES ;i:e %et#ils2 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK &3.
#. -#:e you e:er 7een foun% ;uilty of #ny #%=inistr#ti:e offense
YE YES
O
If ?ES ;i:e %et#ils2
7. -#:e you 7een 0ri=in#lly 0/#r;e% 7efore #ny 0ourt
YE YES
O
If ?ES ;i:e %et#ils2 D#te File%2 St#tus of C#ses2 &*.
&+.
&6.
-#:e you e:er 7een 0on:i0te% of #ny 0ri=e or :iol#tion of #ny l# %e0ree or%in#n0e or re;ul#tion 7y #ny 0ourt or tri7un#l
YE YES
If ?ES ;i:e %et#ils2
-#:e you e:er 7een sep#r#te% fro= t/e ser:i0e in #ny of t/e folloin; =o%es2 resi;n#tion retire=ent %roppe% fro= t/e rolls %is=iss#l ter=in#tion en% of ter= finis/e% 0ontr#0t or p/#se% out (#7olition) in t/e pu7li0 or pri:#te se0tor
YE YES
O
If ?ES ;i:e %et#ils2
#. -#:e you e:er 7een # 0#n%i%#te in # n#tion#l or lo0#l ele0tion /el% it/in t/e l#st ye#r (e0ept $#r#n;#y ele0tion)
YE YES
O
If ?ES ;i:e %et#ils2
7. -#:e you resi;ne% fro= t/e ;o:ern=ent ser:i0e %urin; t/e t/ree (&)=ont/ perio% 7efore t/e l#st ele0tion to pro=ote#0ti:ely 0#=p#i;n for # n#tion#l or lo0#l 0#n%i%#te &.
O
YES
O
If ?ES ;i:e %et#ils2
-#:e you #0Juire% t/e st#tus of #n i==i;r#nt or per=#nent resi%ent of #not/er 0ountry
YE YES
O
If ?ES ;i:e %et#ils (0ountry)2 '@.
#.
Pursu#nt to2 (#) In%i;enous PeopleBs A0t (RA 6&+1) (7) M#;n# C#rt# for Dis#7le% Persons (RA +++) #n% (0) Solo P#rents >elf#re A0t of @@@ (RA 6+) ple#se #nser t/e folloin; ite=s2 Are you # =e=7er of #ny in%i;enous ;roup ;roup
YES
O
If ?ES ple#se spe0ify2 7.
Are you # person it/ it/ %is#7ility %is#7ility
YES
O
If ?ES ple#se spe0ify ID No2 0.
Are you # solo p#rent p#rent
YES
O
If ?ES ple#se spe0ify ID No2 '1. REFERENCES (Person not rel#te% 7y 0ons#n;uinity or #ffinity to #ppli0#nt #ppointee) NAME
ADDRESS
TEL. NO. 825-17-22
994-16-23
723-18-12
'.
I %e0l#re un%er o#t/ t/#t I /#:e person#lly #00o=plis/e% t/is Person#l D#t# S/eet /i0/ is # true 0orre0t #n% 0o=plete st#te=ent pursu#nt to t/e pro:isions of pertinent l#s rules #n% re;ul#tions of t/e Repu7li0 of t/e P/ilippines. P/ilippines. I #ut/ori"e t/e #;en0y /e#%#ut/ori"e% represent#ti:e to :erify:#li%#te t/e 0ontents st#te% /erein. I #;ree t/#t #ny =isrepresent#tion =isrepresent#tion =#%e in t/is t/is %o0u=ent #n% its #tt#0/=ents #tt#0/=ents s/#ll 0#use t/e filin; of #%=inistr#ti:e0ri=in#l #%=inistr#ti:e0ri=in#l 0#ses #;#inst =e.
ID &ict#re ta'en ithin the )a*t + month* ,.- cm. .- cm (&a**&ort *ize$ 0ith #)) an" han"ritten name ta! an" *i!nat#re o1er &rinte" name 2om&#ter !enerate" or &hotoco&ie" &ict#re i* not acce&tab)e
P-OTO
(i.e.P#ssport
S!$SCRI$ED AND S>ORN to 7efore =e t/is
Si;n#ture (Si;n insi%e t/e 7o)
M#y ' @1+ D#te A00o=plis/e%
Ri;/t T/u=7=#r8
#ffi#nt e/i7itin; /is/er :#li%ly issue% ;o:ern=ent ID #s in%i0#te% #7o:e.
Person A%=inisterin; O#t/ CS FORM 1 (Re:ise% (Re:ise% @1+) P#;e '
f '
