CS Form No.

212
Revised 2017
PERSONAL DATA SHEET
WARNING: Any misinterpretation made in the Personal Data Sheet and the Work Experience Sheet shall cause the filing of administrative/criminal case/s against the
person concerned.
READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.
Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE. 1. CS ID No. (Do not fill up. For CSC use only)
I. PERSONAL INFORMATION
23. SURNAME
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME
D(mAmT/EddO/yFyByyIR) TH
16. CITIZENSHIP Dual Citizenship
Filipino
by birth by naturalization
4. PLACE OF BIRTH If holder of dual citizenship, please Pls. indicate country:
5. SEX Male Female indicate the details.

6 CIVIL STATUS Single Married 17. RESIDENTIAL ADDRESS

House/Block/Lot Street
Widowed No.

Subdivision/ Barangay
Separated Other/s: Village

7. HEIGHT (m)
ZIP CODE City/Municipality Province
8. WEIGHT (kg)
18. PERMANENT ADDRESS
9. BLOOD TYPE
House/Block/Lot Street
No.

10. GSIS ID NO.

Subdivision/ Barangay
Village

11. PAG-IBIG ID NO.

ZIP CODE City/Municipality Province
12. PHILHEALTH NO.

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO.

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any)

II. FAMILY BACKGROUND 20. MOBILE NO.

22. 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
SFPIORUSSTEN'SAM

SEURNAME MIDDLE

NAME

OCCUPATION
EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME

NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

25. MOTHER'S MAIDEN NAME

SURNAME

FIRST NAME
(Continue on separate sheet if necessary)
MIDDLE NAME
III. EDUCATIONAL BACKGROUND
HIGHEST
SCHOLARSHIP/
26. PERIOD OF ATTENDANCE LEVEL/
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE YEAR ACADEMIC
LEVEL UNITS
(Write in full) (Write in full) GRADUATED HONORS
From To EARNED
(if not RECEIVED

ELEMENTARY

SECONDARY
VOCATIONAL /

COLLEGE

GRADUATE STUDIES
(Continue on separate sheet if necessary)

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 BARANGAY EXAMINATION PLACE OF EXAMINATION / CONFERMENT Date of
(If Applicable) NUMBER
ELIGIBILITY / DRIVER'S LICENSE / Validity
CONFERMENT

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experience sheet.
INCLUSIVE DATES SALARY/ JOB/
28.
PAY GRADE (if GOV'T
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY STATUS OF
applicable)& STEP SERVICE
(Write in full/Do not abbreviate) (Write in full/Do not abbreviate) SALARY (Format "00-0")/ APPOINTMENT
(Y/ N)
From To INCREMENT

(Continue on separate sheet if necessary)

SIGNATURE DATE

CS FORM 212 (Revised 2017), Page 2 of 4

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29.
(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 Type of LD
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE CONDUCTED/ SPONSORED BY
30. INTERVENTIONS/TRAINING PROGRAMS ( Managerial/
(mm/dd/yyyy) NUMBER OF HOURS
Supervisory/ (Write in full)
(Write in full) From To Technical/etc)

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES (Write in full) 33.
(Write in full)

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 3 of 4
 34.
Are you related by consanguinity or affinity to the appointing or recommending authority, or to
chief of bureau or office or to the person who has immediate supervision over you in the Bureau or
Department where you will be apppointed,
a. within the third degree? YES N
b. within the fourth degree (for Local Government Unit - Career Employees)? YES
O
If YES, give details: N

35. a. Have you ever been found guilty of any administrative offense? YES NO
If YES, give details:

b. Have you been criminally charged before any court? YES NO

If YES, give details:
Date Filed:
Status of Case/s:
36. rHeagvuelaytiooun ebvyear nbyeeconucrot novrictrtiebdunoafla?ny crime or violation of any law, YES NO
decree, ordinance or If YES, give details:

37. Hreativremyoeunte, vderorpbpeeednfsroempatrhaeterdolflrso,mdisthmeisssearlv, YES NO

itceermininaantyioonf, tehnedfoflotewrimng, fminoisdheesd: rceosnigtrnaact oonr , phased out If YES, give details:
(abolition) in the public or private sector?
38. (ae.xHcaevpet Byaoruaenvgearybeelecntiaonc)a?ndidate in a national or local election held within the YES NO
last year If YES, give details:
YES NO
tbh.eHlaset eyloeuctiroensitgonperdofmroomte/tahcetigvoevlyercnammepnatigsnerfvoircea If YES, give details:
dnuartinognathl oerthlorceael (c3a)n-mdiodnate?period before
39. Have you acquired the status of an immigrant or permanent resident of another country? YES NO
If YES, give details (country):

40.
(PRuArs7u2a7n7t )to; :a(nad) (Icn)dSigoelnooPuasrPenetospWle'eslfAarcet (ARcAt
o8f327010);0((bR) AM8a9g7n2a)C, palretasfeoraDnisswaebrletdhePeforlsloownsing 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:

41. 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
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete
Computer generated or
statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. I authorize photocopied picture is
the agency head/authorized representative to verify/validate the contents stated herein. I agree that any not acceptable

misrepresentation made in this document and its attachments shall cause the filing of administrative/criminal
PHOTO
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.

Person Administering Oath

CS FORM 212 (Revised 2017), Page 4 of 4