CS FORM 212 (Revised 2005) PERSONAL DATA SHEET Print legibly. Mark appropriate boxes with “” and use separate sheet if necessary.
I. PERSONAL INFORMATION
2. SURNAME FIRST NAME MIDDLE NAME
3. NAME EXTENSIONS (EG. Jr., Sr.)
4. date of birth (mm/dd/yyyy)	16. residential address
5. place of birth	Batac, Ilocos Norte
6. sex	Male Female
7. civil status	Single Widowed Married Separated Annulled Others, specify__________	zip code
17. telephone no.
8. citizenship	18. permanent address zip code 19. telephone number
9. height (m)
10. weight (kg)
11. blood type
12. gsis id no.	20. e-mail address (if any)
13. pag-ibig id no.	21. cellphone no. (if any)
14. philhealth nc.	22. agency employee no.
15. sss no.	23. tin
II. FAMILY BACKGROUND
24. spouse’s surname first name middle name	25. name of child (Write full name and list all)	date of birth (mm/dd/yyyy)
occupation
employer/bus. name
business ADDRESS
telephone no.
26. father’s surname first name middle name
27. mother’s maiden name surname first name MIDDLE NAME
28. level	name of school (Write in full)	degree course (Write in full)	year graduated (if graduated)	highest grade/ level/ units earned (if not graduated)	inclusive dates of attendance	scholarship/ academic honors recieved
From	To
elementary
secondary
vocational/ trade course
college
graduate studies
IV. CIVIL SERVICE ELIGIBILITY
29. career service/ RA 1080 (board/bar) under special laws/ CES/ CSEE	rating	date of examination/ conferment	place of examination/ conferment	license if applicable
number	date of release
(Continue on separate sheet if necessary) MARIFE D. CARPIO
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IV. WORK EXPERIENCE (Include private employment. Start from your current work)
30. inclusive dates (mm/dd/yyyy)	position title (Write in full)	department / agency / office / company (Write in full)	monthly salary	salary grade & step increment (Format “00-0”)	gov’t service (Yes/ No)
From	To
VI. VOLUNTARY WORK IN CIVIC/ NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATIONS
31. name & address of organization (Write in full)	inclusive dates (mm/dd/yyyy)	number of hours	position / nature of work
From	To
VII. TRAINING PROGRAMS (Start from the most recent training.)
32.title of seminar/ conference/ workshop/ short courses (Write in full)	inclusive dates (mm/dd/yyyy)	number of hours	conducted/ sponsored by (Write in full)
From	To
VIII. OTHER INFORMATION
33. special skills and hobbies:	34. non-academic distinctions / recognition: (Write in full)	35. membership in association / organization (Write in full)
36. Are you related by consanguinity or affinity to any of the following: Within the third degree (for National Government Employees): appointing authority, recommending 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? Within the fourth degree (for Local Government Employees): appointing authority or recommending authority where you will be appointed?	YES NO If YES, give details: _________________________________________________________________________________________________________________________________________________________ YES NO If YES, give details: _________________________________________________________________________________________________________________________________________________________
37. Have you ever been formally charged? Have you ever been guilty of any administrative offense?	YES NO If YES, give details: _________________________________________________________________________________________________________________________________________________________ YES NO If YES, give details: _________________________________________________________________________________________________________________________________________________________
(Continue on separate sheet if necessary) MARIFE D. CARPIO
CS FORM 212 (Revised 2005). Page 2 of 3
38. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal?	YES NO If YES, give details: _________________________________________________________________________________________________________________________________________________________
39. Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped from the rolls, dismissal, termination, end of term, finished contract, AWOL or phased out, in the public or private sector?	YES NO If YES, give details: _________________________________________________________________________________________________________________________________________________________
40. Have you ever been a candidate in a national or local election (except Barangay election)?	YES NO 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 8927), please answer the following items: Are you a member of any indigenous group? Are you differently abled? Are you a solo parent?	YES NO If YES, please specify:_________________________________ YES NO If YES, please specify:_________________________________ YES NO If YES, please specify:_________________________________
42. 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 Computer Generated or Xerox copy of picture is not acceptable
MADDUL, SONWRIGHT B.	BSU, La Trinidad, Benguet 2601	421-8277
SITO, LEONILA	CTE, BSU, La Trinidad, Benguet 2601
LANDO, LILY ANN	ACD, PCARRD, Los Baños, Laguna
43. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and complete statement pursuant to the provisions of 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.
MARIFE D. CARPIO
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