Beruflich Dokumente
Kultur Dokumente
212
Revised 2017
I. PERSONAL INFORMATION
2. SURNAME
NAME EXTENSION (JR., SR)
FIRST NAME
MIDDLE NAME
3. DATE OF BIRTH
(mm/dd/yyyy) 1/8/1991 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by by
✘
birth naturalization
4. PLACE OF BIRTH LUCENA CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female
6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS
Separat House/Block/Lot No. Street
Widowed
Other/s: ed
Subdivision/Village Barangay
7. HEIGHT (m)
City/Municipality Province
8. WEIGHT (kg) ZIP CODE
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any)
MIDDLE NAME
OCCUPATION
EMPLOYER/BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.
MIDDLE NAME
SURNAME
FIRST NAME
SECONDARY /
VOCATIONAL N/A N/A N/A
SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (if applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity
SIGNATURE DATE
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 /
From To
COMPUTER LITERATE
COOKING
DANCING
SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S
CONDUCTED/ SPONSORED BY
(Write in full)
eparate sheet if necessary)
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘ NO
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? YES If YES, give details:
✘ NO
b. Have you resigned from the government service during the three (3)-month period before the last
election to promote/actively campaign for a national or local candidate? YES If YES, give details:
✘ NO
39. Have you acquired the status of an immigrant or permanent resident of another country?
If YES, give details (country):
40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA YES ✘ NO
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
Computer generated
42. or photocopied picture
I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and is not acceptable
complete 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 PHOTO
administrative/criminal case/s against me.
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.