CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes with " " and use separate sheet if necessary. 1. CS ID No. (to be filled up by CSC)
I. PERSONAL INFORMATION
2. S!"#M$ % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % %
&'!S( "#M$ % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % %
M'))*$ "#M$
% % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % +. "#M$ $,($"S'-" (e.g. .r./ Sr.)
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II. FAMILY BACKGROUND
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III. EDUCATIONAL BACKGROUND
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52.
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(if not graduated)
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Single
Married

?idowed
Separated

Male &e3ale
I&. CI&IL SER&ICE ELIGIBILITY
2<.
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&. 'ORK E(PERIENCE (In#)u*e pi+ate e,p)o$,ent. Stat "o, $ou #uent -o.%
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CS &-!M 252 (!eDised 2>>7)/ Page 2 of 0
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&I. &OLUNTARY 'ORK OR IN&OL&EMENT IN CI&IC / NON0GO&ERNMENT / PEOPLE / &OLUNTARY ORGANI1ATION/S
+5.
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&II. TRAINING PROGRAMS (Stat "o, t!e ,ost e#ent tainin2.%
+2.
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&III. OT3ER INFORMATION
++. SP$C'#* SF'**S 4 2-11'$SG +0. +7.
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CS &-!M 252 (!eDised 2>>7)/ Page + of 0
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+6.
#re you related by consanguinity or affinity to any of the following G
a.
b.
+8 a. 2aDe you eDer been for3ally chargedH
b. 2aDe you eDer been guilty of any ad3inistratiDe offenseH
+;.
+<.
0>. 2aDe you eDer been a candidate in a national or local election (except 1arangay election)H
05.
a.
#re you a 3e3ber of any indigenous groupH
'f @$S/ please specifyG CCCCCCCCCCCCCCCCCCCC
b.
#re you differently abledH
'f @$S/ please specifyG CCCCCCCCCCCCCCCCCCCC
c.
#re you a solo parentH
'f @$S/ please specifyG CCCCCCCCCCCCCCCCCCCC
02.
"#M$ #))!$SS ($*. "-.
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CS &-!M 252 (!eDised 2>>7)/ Page 0 of 0
?ithin the third degree (for "ational =oDern3ent $3ployees)G
appointing authority/ reco33ending authority/ chief of office4bureau4depart3ent or person who
has i33ediate superDision oDer you in the -ffice/ 1ureau or )epart3ent where you will be
appointedH
'f @$S/ giDe detailsG
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
?ithin the fourth degree (for *ocal =oDern3ent $3ployees)G
appointing authority or reco33ending authority where you will be appointedH
'f @$S/ giDe detailsG
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
'f @$S/ giDe detailsG
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
'f @$S/ giDe detailsG
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
2aDe you eDer been conDicted of any cri3e or Diolation of any law/ decree/ ordinance or
regulation by any court or tribunalH
'f @$S/ giDe detailsG
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
2aDe you eDer been separated fro3 the serDice in any of the following 3odesG resignation/
retire3ent/ dropped fro3 the rolls/ dis3issal/ ter3ination/ end of ter3/ finished contract/ #?-*
or phased out/ in the public or priDate sectorH
'f @$S/ giDe detailsG
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
'f @$S/ giDe detailsG
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC
Pursuant toG (a) 'ndigenous PeopleBs #ct (!# ;+85)I (b) Magna Carta for )isabled Persons (!#
8288)I and (c) Solo Parents ?elfare #ct of 2>>> (!# ;<82)/ please answer the following ite3sG
!$&$!$"C$S (Person not related by consanguinity or affinity to applicant 4 appointee)
' declare under oath that this Personal )ata Sheet has been acco3plished by 3e/ and is a true/ correct and
co3plete state3ent pursuant to the proDisions of pertinent laws/ rules and regulations of the !epublic of the
Philippines.
' also authoriJe the agency head 4 authoriJed representatiDe to Derify 4 Dalidate the contents stated herein. ' trust
that this infor3ation shall re3ain confidential.
S'="#(!$ (Sign inside the box)
ID picture taken within
the last 6 months
3.5 cm. X 4.5 cm
(passport size)
Computer generated
or ero cop! o" picture
is not accepta#le

@$S "-
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