CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

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

I. PERSONAL INFORMATION
2. SURNAME | | | | | | | | | | | | | | | | | | | |

FIRST NAME | | | | | | | | | | | | | | | | | | | |

MIDDLE NAME | | | | | | | | | | | | | | | | | | | |
4. DATE OF BIRTH (mm/dd/yyyy) 16. RESIDENTIAL ADDRESS

5. PLACE OF BIRTH

 Male  Female
6. SEX
7. CIVIL STATUS
Single Widowed ZIP CODE

Married Separated 17. TELEPHONE NO.

Annulled 
Others, specify ___________
18. PERMANENT ADDRESS

8. CITIZENSHIP

9. HEIGHT (m)

10. WEIGHT (kg) ZIP CODE

11. BLOOD TYPE 19. TELEPHONE NO.

12. GSIS ID NO. 20. E-MAIL ADDRESS (if any)

13. PAG-IBIG ID NO. 21. CELLPHONE NO. (if any)

14. PHILHEALTH NO. 22. AGENCY EMPLOYEE NO.

15. SSS NO. 23. TIN

II. FAMILY BACKGROUND

24.SPOUSE'S SURNAME 25. NAME OF CHILD (Write full name and list all)
DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME / /

MIDDLE NAME / /

OCCUPATION / /

EMPLOYER/BUS. NAME / /

BUSINESS ADDRESS / /

TELEPHONE NO. / /

(Continue on separate sheet if necessary) / /

26. FATHER'S SURNAME / /

FIRST NAME / /

MIDDLE NAME / /

27. MOTHER'S MAIDEN NAME / /

SURNAME / /

FIRST NAME / /

MIDDLE NAME YEAR (Continue on separate sheet if necessary)

GRADUATE
III. EDUCATIONAL BACKGROUND D
HIGHEST
GRADE/ LEVEL/ INCLUSIVE DATES OF
28. NAME OF SCHOOL DEGREE COURSE SCHOLARSHIP/
UNITS ATTENDANCE
LEVEL (Write in ACADEMIC
EARNED
(Write in full) full) From To HONORS RECEIVED
(if not
graduated)
(if
ELEMENTARY
graduated
)
SECONDARY /
VOCATIONAL

COLLEGE
TRADE COURSE

GRADUATE STUDIES

(Continue on separate sheet if necessary)

Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
29. DATE OF LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/
EXAMINATIO
BAR) UNDER SPECIAL LAWS/ CES/ RATING PLACE OF EXAMINATION / CONFERMENT
N/ NUMBER DATE OF
CSEE
CONFERMENT RELEASE

(Continue on separate sheet if necessary)

GOV'T
V. WORK EXPERIENCE (Include private employment. Start from your current work) SERVICE
SALARY
30. INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / GRADE & STATUS OF
(mm/dd/yyyy) COMPANY MONTHLY STEP
APPOINTMEN
(Write in SALARY INCREMENT
T
(Format "00-
From To (Write in full) full) 0")
(Yes /
/ / / / No)

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2005), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANI
INCLUSIVE DATES
31. NAME & ADDRESS OF ORGANIZATION NUMBER
(Write in full) POSITION / NATURE OF WORK
(mm/dd/yyyy) OF HOURS
From To

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

(Continue on separate sheet if necessary)

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

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

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION MEMBERSHIP IN

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

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2005), Page 3 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANI
INCLUSIVE DATES
31. NAME & ADDRESS OF ORGANIZATION NUMBER
(Write in full) POSITION / NATURE OF WORK
(mm/dd/yyyy) OF HOURS
From To

/ /

/ / / /

/ / / /

/ / / /

/ / / /

(Continue on separate sheet if necessary)

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

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

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION MEMBERSHIP IN

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

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2005), Page 3 of 4
36. Are you related by consanguinity or affinity to any of the following :

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

 YES 
appointing authority, recommending If YES, give details:
authority, chief of office/bureau/department or person who 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): ____________________________________

 YES
_


appointing authority or recommending If YES, give details:
authority where you will be appointed? ____________________________________
_
____________________________________
_
37 a. Have you ever been formally charged?
____________________________________

 YES 
_
If YES, give details:
________________________________
________________________________

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

 YES 
If YES, give details:
________________________________
________________________________
38. Have you ever been convicted of any crime or violation of any law,

 YES 
decree, ordinance or regulation by any court or tribunal? If YES, give details:
________________________________
________________________________
39. Have you ever been separated from the service in any of the following

 YES 
modes: resignation, retirement, dropped from the rolls, dismissal,
termination, end of term, finished contract, AWOL or phased out, in If YES, give details:
the public or private sector? ________________________________
________________________________

40. Have you ever been a candidate in a national or local election (except

 YES 
Barangay election)?
If YES, give details:
________________________________
________________________________
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 
If YES, please specify: ____________________
b. Are you differently abled?

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

 YES 
If YES, please specify: ____________________
42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)

NAME ADDRESS TEL. NO.

MAGDALENA C. MEANA, M.D. 8612459

Muntinlupa City Health Office,Poblacion
ID picture taken within
the last 6 months
ELSA DE MESA-OLEA 8612460
Muntinlupa City Health Office,Poblacion 3.5 cm. X 4.5 cm
(passport size)

Computer generated
43. I declare under oath that this Personal Data Sheet has been accomplished by me, or xerox copy of picture
and is a true, correct and complete statement pursuant to the provisions of is not acceptable

pertinent laws, rules and regulations of the Republic of the Philippines.

I also authorize the agency head / authorized representative to verify / validate the
contents stated herein. I trust that this information shall remain confidential. PHOTO

COMMUNITY TAX CERTIFICATE NO.

Muntinlupa City
ISSUED AT SIGNATURE (Sign inside the box)

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

CS FORM 212 (Revised 2005), Page 4 of 4