CS FORM 212 (Revised 2005)
PERSONAL DATA SHEET Print legibly. Mark appropriate boxes
with "
1. CS ID No.
" and use separate sheet if necessary.
(to be filled up by CSC)
I. PERSONAL INFORMATION % & $ &
2. S! S!#M #M$ $
' & # &
& !
&
*!S+ #M$
% & $ & M & $ &
M*%%'$ #M$
, & # & ! & ! & & - &
+ & ! & *
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%#<P# C*+= Male
7. S$/ :. C*?*' S+#+ S+#+S S
-*P C%$
Married
Separated
#nnulled
thers1 specify 8;. P$!M#$+ #%%!$SS
9. 3$*<3+ 3$*<3+ (4)
5'8"
86. 86. @$*<3 @$*<3+ + (kg) (kg)
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88. 88. ,'% ,'% +=P$
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& . #M$ $/+$S* (e.g. 0r.1 Sr.)
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266 696::>97>2
8:. +$'$P3$ .
86: +#M,#C %*S+!* C+1 %#<P# C*+=1 C*+=1 P#<#S*#
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266
89. +$'$P3$ .
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26. $AM#*' #%%!$SS (if any)
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28. C$''P3$ . (if any)
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8. P3*'3$#' P3*'3$#'+3 +3 . .
22. #<$C= $MP'=$$ .
8>. 8>. SS SSS S . .
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82. 82.
&
e4ale @idowed
FILIPINO
&
&
86: +#M,#C %*S+!* C+1 %#<P# C*+=1 C*+=1 P#<#S*#
Single
;. C*+*-$ C*+*-$S3 S3*P *P
&
87. !$S*%$+*#' #%%!$SS
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. %#+$ ,*!+3 ,*!+3 (445dd5yyyy) (445dd5yyyy) >. P'#C$ P'#C$ ,*!+3 ,*!+3
&S
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II. FAMIL FAMILY Y BACKGROUND 2. SPS$B SPS$BS S!#M S!#M$ $
%$'# !S#
2>. #M #M$ C3*'% (@rite full na4e and list all)
%#+$ ,*!+3 (445dd5yyyy)
*!S+ #M$
&IR!I
%$?*$ . %$'# !S#
65875266;
M*%%'$ #M$
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%$M?$! . %$'# !S#
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%$27. #+3$!BS S!#M$
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%$'# !S# S!.
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%$M$+!*
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2:. M+3$!BS M#*%$ #M$ S!#M$
%$'# !S#
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$SP$!#-#
M*%%'$ #M$
,#!!-
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%$III. EDUCA EDUCATIONAL TIONAL BACKGROUND 2;.
#M$ SC3' '$?$'
(@rite in
%$
full)
$'$M$+#!=
+#M,#C $'$M$+#!= SC3'
8998
S$C%#!=
S+. 03 C#+3$%!#' 3*<3 SC'
899>
C''$<$
*C'S*?$ %#+$S #++$%#C$
3*<3$S+
(@rite in full)
ro4
+o
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899>
*?$!S*+= P#<#S*#
,#C3$'! SC*$C$ * CMP+$! 266 $<*$$!*<
899>
2666
% M#!*# M#!CS M$M!*#' S+#+$ S+#+$ *?$!S*+= *?$! S*+=
M.#. * M#+3$M#+*CS
266:
2669
2666
SC3'#!S3*P5 #C#%$M*C 3!S !$C$*?
%$+3$ MS+ !$C$P*$+ * %$S*< P!0$C+ * ,SCP$
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%$Page 8 of
I&. CI&IL SER&ICE ELIGIBILITY 29.
C#!$$! S$!?*C$5 !# 86;6 (,#!%5 ,#!) %$! SP$C*#' '#@S5 C$S5 CS$$
PROFSSION*L C*RR SR&IC
!#+*<
;.>6D
N*+ION*L CR+IFIC*+(NC;2) COMP+R *RD<*R SR&ICIN!
'*C$S$ (if applicable)
%#+$ $/#M*#+* 5 C$!M$+
P'#C$ $/#M*#+* 5 C$!M$+
M,$!
%#+$ !$'$#S$
6:5252662
CSC C*R R!ION
66868@$
6:5252662
86525266;
+SD* LIN!*,N- P*N!*SIN*N
6968662669:6 6258>52669
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%$&. 'ORK EPERIENCE (In#)u*e pi+ate e,p)o$,ent. Stat "o, $ou #uent -o% 6.
*C'S*?$ %#+$S (445dd5yyyy) ro4
PS*+* +*+'$ (@rite in full)
+o
%$P#!+M$+ 5 #<$C= 5 *C$ 5 CMP#= (@rite in full)
M+3'= S#'#!=
S#'#!=
<?B+ S$!?*C$ S+#+S #PP*+M$+ (=es 5 o)
6:58752666
685 875266
MIS S
J*P*N CIRCI+ +CNOLO!, CORPOR*+ION/Po34ee De7e
86666
!$<'#!
6 5825266
6 5 2; 52669
I+ Is43o
ivesi o L49o
82666
!$<'#!
6 52; 52682
Co74e Is43o/Rese3=e
Do Mio M3os Meoi: Se ivesi
89666
!$<'#!
yes
69 5 8852669
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5 (Continue on sepaate s!eet i" ne#essa$% CS !M 282 (!eEised 266>)1 Page 2 of
&I. &OLUNTARY 'ORK OR IN&OL&EMENT IN CI&IC / NON0GO&ERNMENT / PEOPLE / &OLUNTARY ORGANI1ATION/S *C'S*?$ %#+$S 8.
#M$ F #%%!$SS !<#*-#+* (@rite in full)
M,$! 3!S
(445dd5yyyy) ro4
*SSOCI*+ION OF COMP+R N!INRIN! S+DN+ CONCIL
PS*+* 5 #+!$ @!G
+o
67 5 82 5899>
675 8 5899:
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26 3!S M$M,$! S+%$+ CC*'
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%$&II. TRAINING PROGRAMS (Stat "o, t!e ,ost e#ent tainin2.% *C'S*?$ %#+$S #++$%#C$ 2.
+*+'$ S$M*#!5C$!$C$5@!GS3P5S3!+ C!S$S (@rite in full)
M,$! 3!S
(445dd5yyyy) ro4
C%C+$%5 SPS!$% ,= (@rite in full)
+o
D*+* COMMNIC*+IONS *ND N+
6;52858999
6;522 58999
87 3!S #+*#'CMP+$! C$+$!
<P*! DSI!N *ND N+
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+M+P 1
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3!S +$S%# '*<#=$ P#<#S*#
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3!S +$S%# '*<#=$ P#<#S*#
C*MC
6>58852669
ISO 1001 d ISO $001(>4:i M?ee d vioe *@eess)
6752852666
67 5 22 52666 87 3!S 0apan Circuit +echnology Corporation
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%$&III. OT3ER INFORMATION .
SP$C*#' SG*''S 5 3,,*$SH
.
A#C#%$M*C %*S+*C+*S 5 !$C<*+*H (@rite in full)
>.
#SSC*#+*5!<#*-#+* (@rite
*+$!$+1 C3$SS1 ,#SG$+,#''1 ,#%M*+ $+C.
(Continue on sepaate s!eet i" ne#essa$% CS !M 282 (!eEised 266>)1 Page of
7.
#re you related by consanguinity or affinity to any of the following H
a.
@ithin the third degree (for ational
b.
@ithin the fourth degree (for 'ocal
:
a. 3aEe you eEer been for4ally chargedI
=$S *f =$S1 giEe detailsH =$S
*f =$S1 giEe detailsH =$S
*f =$S1 giEe detailsH =$S
b. 3aEe you eEer been guilty of any ad4inistratiEe offenseI
*f =$S1 giEe detailsH ;.
3aEe you eEer been conEicted of any cri4e or Eiolation of any law1 decree1 ordinance or regulation by any court or tribunalI
9.
3aEe you eEer been separated fro4 the serEice in any of the following 4odesH resignation1 retire4ent1 dropped fro4 the rolls1 dis4issal1 ter4ination1 end of ter41 finished contract1 #@' or phased out1 in the public or priEate sectorI
6.
3aEe you eEer been a candidate in a national or local election (except ,arangay election)I
=$S *f =$S1 giEe detailsH =$S
*f =$S1 giEe detailsH =$S
*f =$S1 giEe detailsH 8.
Pursuant toH (a) *ndigenous PeopleBs #ct (!# ;:8)J (b) Magna Carta for %isabled Persons (!# :2::)J and (c) Solo Parents @elfare #ct of 2666 (!# ;9:2)1 please answer the following ite4sH
a.
#re you a 4e4ber of any indigenous groupI
=$S *f =$S1 please specifyH
b.
#re you differently abledI
=$S *f =$S1 please specifyH
c.
#re you a solo parentI
=$S *f =$S1 please specifyH
2. !$$!$C$S (Person not related by consanguinity or affinity to applicant 5 appointee) #M$
#%%!$SS
$
M#<#'%#1 P#<#S*#
!$$ M=#
M#<#'%#1 P#<#S*#
.
+$'. .
* declare under oath that this Personal %ata Sheet has been acco4plished by 4e1 and is a true1 correct and co4plete state4ent pursuant to the proEisions of pertinent laws1 rules and regulations of the !epublic of the Philippines. * also authoriKe the agency head 5 authoriKed representatiEe to Eerify 5 Ealidate the contents stated herein. * trust that this infor4ation shall re4ain confidential.
ID picture taken within the last 6 months 3.5 cm. X 4.5 cm passport si!e"
#omputer $enerated or %ero% copy o& picture is not accepta'le
P3+
82;2>9 CMM*+= +#/ C$!+**C#+$ .
%#<P# C*+= *SS$% #+
65825268 *SS$% (445dd5yyyy)
S*<#+!$ (Si? iside =e AoB)
885275268 %#+$ #CCMP'*S3
%$!*<3+ +3M,M#!G
CS !M 282 (!eEised 266>)1 Page of