CS FORM 212 (Revised 2012)

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes q with "P " and use separate sheet if necessary. 1. CS ID No. (to be filled up by CSC)

I. PERSONAL INFORMATION
1. SURNAME

FIRST NAME

MIDDLE NAME 3. NAME EXTENSION (e.g. Jr., Sr.)

2. DATE OF BIRTH (mm/dd/yyyy) 13. RESIDENTIAL ADDRESS

3. PLACE OF BIRTH
4. SEX
5 CIVIL STATUS ZIP CODE
Single Widowed
14. TELEPHONE NO.
Married Separated 15. PERMANENT ADDRESS

6. CITIZENSHIP
7. HEIGHT (m)
8. WEIGHT (kg) ZIP CODE
9. BLOOD TYPE 16. TELEPHONE NO.
10. GSIS ID NO. 17. E-MAIL ADDRESS (if any)
1. PAG-IBIG ID NO. 18. CELLPHONE NO. (if any)
2. PHILHEALTH NO. 19. AGENCY EMPLOYEE NO.
3. SSS NO. 20. TIN

II. FAMILY BACKGROUND

21NAME OF SPOUSE

OCCUPATION

EMPLOYER/BUS. NAME

BUSINESS ADDRESS

TELEPHONE NO.

22. NAME OF CHILDREN Date of Birth ( mm/dd/yyyy) NAME OF CHILDREN Date of Birth ( mm/dd/yyyy)

(Continue on separate sheet if necessary)

23NAME OF FATHER FULL MAIDEN NAME OF MOTHER

24. PARENTS ADDRESS

III. EDUCATIONAL BACKGROUND

28LEVEL HIGHEST GRADE/ INCLUSIVE DATES OF SCHOLARSHIP/
LEVEL/ ATTENDANCE
NAME OF SCHOOL DEGREE/ COURSE ACADEMIC
UNITS EARNED
(Write in full) (Write in full) HONORS
(if not From To RECEIVED
graduated)

ELEMENTARY

SECONDARY
VOCATIONAL /

TRADE
COURSE
TERTIARY

GRADUATE STUDIES
*Diploma

*Masters

*Doctorate

NON -DEGREE COURSE

*(course taken aside from Tertiary education but not classified as Graduate Studies)
(Continue on separate sheet if necessary) Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. DATE OF LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
UNDER SPECIAL LAWS/ CES/ CSEE NUMBER DATE OF
CONFERMENT
RELEASE

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work)
28. INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE /
(mm/dd/yyyy) COMPANY MONTHLY SALARY STATUS OF APPOINTMENT
(Write in full) (Write in full)
From To

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2010), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
29 NAME & ADDRESS OF ORGANIZATION NUMBER OF
(Write in full) (mm/dd/yyyy) POSITION / NATURE OF WORK
HOURS
From To

(Continue on separate sheet if necessary)

VII. TRAINING PROGRAMS (Start from the most recent training.)

INCLUSIVE DATES OF ATTENDANCE
30 NUMBER OF CONDUCTED/ SPONSORED BY
TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write in full) (mm/dd/yyyy) HOURS (Write in full)
From To

/ / / /

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION: ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS / HOBBIES: 34. 35.
(Write in full)
(Write in full)

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2010), Page 3 of 4
 34. Are you related by consanguinity or affinity to any of the following :

a. Within the third degree (for National Government Employees):

appointing authority, recommending authority, chief of office/bureau/department or person who If YES, give details: _____________________________________
has immediate supervision over you in the Office, Bureau or Department where you will be _____________________________________
appointed? _____________________________________

b. Within the fourth degree (for Local Government Employees):

appointing authority or recommending authority where you will be appointed? If YES, give details: _____________________________________
_____________________________________
_____________________________________

35 a. Have you ever been formally charged?

If YES, give details: ________________________________
________________________________

b. Have you ever been guilty of any administrative offense?

If YES, give details: ________________________________
________________________________

36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or
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,
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract, AWOL
or phased out, in the public or private sector? If YES, give details: ________________________________
________________________________

38. Have you ever been a candidate in a national or local election (except Barangay election)?
If YES, give details: ________________________________
________________________________

39. 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?

If YES, please specify: ____________________

b. Are you differently abled?

If YES, please specify: ____________________
c. Are you a solo parent?
If YES, please specify:

40. 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)
41. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and complete
statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. Computer generated
or xerox copy of picture
I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust that this is not acceptable

information shall remain confidential.

PHOTO

COMMUNITY TAX CERTIFICATE NO.

SIGNATURE (Sign inside the box)

ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

CS FORM 212 (Revised 2010), Page 4 of 4