CS FORM 212 (Revised 2016) Annex E

PERSONAL DATA SHEET

Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE. 1. CS ID No.

I. PERSONAL INFORMATION
2. SURNAME

FIRST NAME 3. EXTENSION NAME (JR., S

MIDDLE NAME

4. DATE OF BIRTH (mm/dd/yyyy) 17. CITIZENSHIP

Filipino Dual Citi

5. PLACE OF BIRTH If holder of a foreign or dual citizenship,

Male Female please indicate the details.

6. SEX

Single Married 18. RESIDENTIAL ADDRESS

7. CIVIL STATUS
Widowed Separated House/Block/Lot No. S
Other/s:
Subdivision/Village Bar

8. HEIGHT (m)
City/Municpality Pro
9. WEIGHT (kg) ZIP CODE

19. PERMANENT ADDRESS

10. BLOOD TYPE
House/Block/Lot No. S

11. GSIS ID NO.

Subdivision/Village Bar

12. PAG-IBIG ID NO.

City/Municpality Pro

13. PHILHEALTH NO. ZIP CODE

14. SSS NO. 20. TELEPHONE NO.

15. TIN NO. 21. MOBILE NO.

16. AGENCY EMPLOYEE NO. 22. E-MAIL ADDRESS (if any)

II. FAMILY BACKGROUND

23. SPOUSE'S SURNAME 24. NAME of CHILDREN (Write full name and list all)

EXTENSION NAME (JR., SR)

FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUS. NAME

BUSINESS ADDRESS

TELEPHONE NO.

25. FATHER'S SURNAME

EXTENSION NAME (JR., SR)

FIRST NAME

MIDDLE NAME

26. MOTHER'S MAIDEN NAME

SURNAME

FIRST NAME

MIDDLE NAME (Continue on separate sheet if nece

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL HIGHEST LEVEL/
27. DEGREE/COURSE (Write PERIOD OF ATTENDANCE UNITS
LEVEL EARNED
in full)
(Write in full) (if not graduated)
From To

ELEMENTARY

SECONDARY
VOCATIONAL /

TRADE COURSE
COLLEGE

GRADUATE STUDIES

(Continue on separate sheet if necessary)

Signature Date
CS FORM 21
 Annex E

DATA SHEET
(to be filled up by CSC)

3. EXTENSION NAME (JR., SR)

Dual Citizenship

Street

Barangay

Province

Street

Barangay

Province

DATE OF BIRTH
(mm/dd/yyyy)

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED
parate sheet if necessary)

CS FORM 212 (Revised 2016), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY
28. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (if appli
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work) Description of duties should be indicated in the attached Professional Experience sheet.

29. INCLUSIVE DATES SALARY/ JOB/ PAY

POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in (Write in SALARY
applicable)& STEP
APPOINTMENT
full/Do not abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To

(Continue on separate sheet if necessary)

Signature Date
CS FORM 212 (Revised 2016)
 LICENSE (if applicable)

Date of
Validity

rate sheet if necessary)

tion of duties should be indicated in the attached Professional Experience sheet.

GOV'T
SERVICE

(Y/ N)

rate sheet if necessary)

CS FORM 212 (Revised 2016), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
30 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
31 TITLE OF LEARNING AND DEVELOPMENT ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
INTERVENTIONS/TRAINING PROGRAMS (Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION
MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
32. SPECIAL SKILLS and HOBBIES 33. 34.
(Write in full)
(Write in full)

(Continue on separate sheet if necessary)

Signature Date
CS FORM 212 (Revised 2016), Page 3 of 4
 35. 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 Employees)? YES NO

If YES, give details:

________________________________

36. a. Have you ever been found guilty of any administrative offense? YES NO

If YES, give details:

________________________________
________________________________

b. For PNP Uniformed Personnel, pursuant to Sec. 38(a) of RA 6975, as amended. YES NO
Have you been criminally charged before any court? If YES, give details:
________________________________
Date Filed:
________________________________
Status of Case/s:
37. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation YES NO
by any court or tribunal?
If YES, give details:
________________________________
________________________________
38. Have you ever been separated from the service in any of the following modes: resignation, YES NO
retirement, dropping from the rolls, dismissal, termination, end of term, finished contract, AWOL or If YES, give details:
phased out (abolition) in the public or private sector? ________________________________
________________________________
39. Have you ever been a candidate in a national or local election held within the last year (except YES NO
Barangay election)?
If YES, give details:

40. Have you acquired the status of an immigrant or permanent resident of another country? YES NO
If YES, give details (country):

41. 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:

42. 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
43. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and Computer generated
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the or xerox copy of picture
is not acceptable
Philippines.
I also authorize the agency head / authorized representative to verify / validate the contents stated herein.
PHOTO
I agree that any misrepresentation made in this document shall cause the filing of administrative/criminal case/s
against me.

Government Issued ID (i.e.GSIS, SSS, PRC, Driver's etc.)

PLEASE INDICATE ID Number and Date of Issuance

Government Issued ID:

ID Number:
Signature (Sign inside the box)

Date of Issuance:
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.

Person Administering Oath

CS FORM 212 (Revised 2016), Page 4 of 4