Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
212
Revised 2017
I. PERSONAL INFORMATION
2. SURNAME
NAME EXTENSION (JR., SR)
FIRST NAME
MIDDLE NAME
3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) Filipino Dual Citizenship
by birth by naturalizati
4. PLACE OF BIRTH If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m)
City/Municipality Province
8. WEIGHT (kg) ZIP CODE
18. PERMANENT ADDRESS
9. BLOOD TYPE
House/Block/Lot No. Street
MIDDLE NAME
OCCUPATION
EMPLOYER/BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.
MIDDLE NAME
SURNAME
FIRST NAME
VOCATIONAL /
SECONDARY
COLLEGE TRADE
COURSE
GRADUATE STUDIES
SIGNATURE DATE
CS FORM 212 (Revised 2017), P
e/s against the
uralization
ry:
RTH (mm/dd/yyyy)
SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED
ed 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
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (Write in
full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To
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 theof bureau or office or to the person who has immediate supervision over you in the
chief
Office,
Bureau or Department where you will be apppointed,
a. within the third degree? YES ✘ NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘ NO
If YES, give details:
________________________________
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. Have you ever been convicted of any crime or violation of any law, decree, ordinance or
YES ✘ NO
regulation by any court or tribunal?
If YES, give details:
________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation, ✘ YES NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or If YES, give details:
phased out (abolition) in the public or private sector? ________________________________
Resigned from LBPSC due to regularization
________________________________
with LANDBANK in 2005.
38. a. Have you ever been a candidate in a national or local election held within the last year
YES ✘ NO
(except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
the last election to promote/actively campaign for a national or local candidate? If YES, give details:
39. Have you acquired the status of an immigrant or permanent resident of another country?
YES ✘ NO
If YES, give details (country):
40. 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
a.
items:
Are you a member of any indigenous group? ✘ YES NO
If YES, please specify: Aromanen Menuvu
b. Are you a person with disability? ✘ YES NO
If YES, please specify ID No: 11-2402-021-621
c. Are you a solo parent? YES ✘ NO
If YES, please specify ID No:
EVA C. SONICO LBP KIDAPAWAN BRANCH (064) 577-1685 With full and handwritten
name tag and signature over
printed name
LORNA G. OMANDAM LBP KIDAPAWAN BRANCH (064) 577-1685
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct or photocopied picture
is not acceptable
and 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 PHOTO
filing of administrative/criminal case/s against me.
SUBSCRIBED AND SWORN to before me this 13th June 2019 , affiant exhibiting his/her validly issued government ID as indicated above.