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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

I. PERSONAL INFORMATION

2. S!#M$ % % % % % % % % % % % % % % % % % % % %

&'!S #M$ % % % % % % % % % % % % % % % % % % % % % % % % % % % % %

M'*$ #M$ % % % % % % % % % % % % % % % % % % % +. #M$ $,$S'- (e.g. r./ Sr.)

0. #$ -& 1'! (334dd4yyyy) 56. !$S'$'#* #!$SS

7. P*#C$ -& 1'!

6. S$,

8. C'9'* S#S :'P C-$

58. $*$P-$ -.

5;. P$!M#$ #!$SS

;. C'':$S'P

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I&. CI&IL SER&ICE ELIGIBILITY

2.

S#S -& #PP-'M$

&ro3 o

D

C#!$$! S$!9'C$4 !# 5>;> (1-#!4 1#!)$! SP$C'#* *#?S4 C$S4 CS$$

#$ -&$,#M'#'- 4C-&$!M$

'C*S'9$ #$S(334dd4yyyy) P-S''- '*$

(?rite in full)

$P#!M$ 4 #=$C@ 4 -&&'C$ 4 C-MP#@

(?rite in full)

M-*@

S#*#!@

S#*#!@ =!#$ FS$P 'C!$M$

(&or3at ">>A>")

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&I. &OLUNTARY 'ORK OR IN&OL&EMENT IN CI&IC / NON0GO&ERNMENT / PEOPLE / &OLUNTARY ORGANI1ATION/S

+5.

P-S''- 4 #!$ -& ?-!G

&ro3 o

4 4

4 4

4 4

4 4

&II. TRAINING PROGRAMS (Stat "o, t!e ,ost e#ent tainin2.%

+2.

C-C$4 SP-S-!$ 1@ (?rite in fu

&ro3 o

(Continue on sepaate s!eet i" ne#essa$%

&III. OT3ER INFORMATION

++. SP$C'#* SG'**S 4 -11'$SH +0. +7.

(Continue on sepaate s!eet i" ne#essa$%

CS &-!M 252 (!eEised 2>>7

#M$ F #!$SS -& -!=#':#'-(?rite in full)

M1$! -&-!S

'*$ -& S$M'#!4C-&$!$C$4?-!GS-P4S-!C-!S$S (?rite in full)

'C*S'9$ #$S -$#C$

(334dd4yyyy)

M1$! -&-!S

-A#C#$M'C 'S'C'-S 4 !$C-=''-H

(?rite in full)

M$M1$!S'P ' #SS-C'#'-4-!=#':#'-

(?rite in full)

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+6. #re you related by consanguinity or affinity to any of the following H

a.

b.

+8 a. aEe you eEer been for3ally chargedI

b. aEe you eEer been guilty of any ad3inistratiEe offenseI

+;.

+. aEe you eEer been a candidate in a national or local election (except 1arangay election)I

05.

a. #re you a 3e3ber of any indigenous groupI

'f @$S/ please specifyH

b. #re you differently abledI

'f @$S/ please specifyH

c. #re you a solo parentI

'f @$S/ please specifyH

02. !$&$!$C$S (Person not related by consanguinity or affinity to applicant 4 appointee)

#M$ #!$SS $*. -.

0+.

P--

C-MM'@ #, C$!'&'C#$ -.

'SS$ #

'SS$ - (334dd4yyyy) #$ #CC-MP*'S$ !'= M1M#!G

CS &-!M 252 (!eEised 2>>7)/ Page 0 of 0

?ithin the third degree (for ational =oEern3ent $3ployees)Happointing authority/ reco33ending authority/ chief of office4bureau4depart3ent or person whohas i33ediate superEision oEer you in the -ffice/ 1ureau or epart3ent where you will beappointedI

'f @$S/ giEe detailsH

?ithin the fourth degree (for *ocal =oEern3ent $3ployees)Happointing authority or reco33ending authority where you will be appointedI 'f @$S/ giEe detailsH

'f @$S/ giEe detailsH

'f @$S/ giEe detailsH

aEe you eEer been conEicted of any cri3e or Eiolation of any law/ decree/ ordinance orregulation by any court or tribunalI 'f @$S/ giEe detailsH

aEe you eEer been separated fro3 the serEice in any of the following 3odesH resignation/retire3ent/ dropped fro3 the rolls/ dis3issal/ ter3ination/ end of ter3/ finished contract/ #?-* orphased out/ in the public or priEate sectorI 'f @$S/ giEe detailsH

'f @$S/ giEe detailsH

Pursuant toH (a) 'ndigenous PeopleBs #ct (!# ;+85)J (b) Magna Carta for isabled Persons (!#8288)J and (c) Solo Parents ?elfare #ct of 2>>> (!# ;