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CIVIL STATUS5.7.8.9.11.PLACE OF BIRTH HEIGHT (m)13. WEIGHT (kg)ADDRESS15. BLOOD TYPE CITIZENSHIP6.14. OCCUPATIONBUSINESS ADDRESS24.II. FAMILY BACKGROUNDIII. EDUCATIONAL BACKGROUNDLEVEL ELEMENTARY SECONDARYGRADUATE STUDIES FromToRATING29.NUMBER OF HOURS30.31.32.33.34.36.ZHave you ever been a candidate in a national or local election (except Barangay election)?38.39. TELEPHONE NO.IV. CIVIL SERVICE ELIGIBILITYNAMEINCLUSIVE DATES (mm/dd/yyyy)EMPLOYER/BUS. NAMESPECIAL SKILLS / HOBBIES:POSITION TITLE (Write in full)I. PERSONAL INFORMATIONVIII. OTHER INFORMATIONPOSITION / NATURE OF WORK_VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S40.41.LICENSE (if applicable)? CONDUCTED/ SPONSORED BY (Write in full)Yes/NoYesNoCstatSingleMarried SeparatedWidowedGenderMaleFemaleINCLUSIVE DATES OF ATTENDANCEVOCATIONAL / TRADE COURSEPAG-IBIG ID NO.PHILHEALTH NO.BCAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEEMONTHLY SALARYSTATUS OF APPOINTMENT 1. CS ID No.OV. WORK EXPERIENCE (Include private employment. Start from your current work)-SALARY GRADE & STEP INCREMENT (Format "00-0") Page 1 of 4)(Continue on separate sheet if necessary)UREFERENCES (Person not related by consanguinity or affinity to applicant / appointee) 10.12.35.3742.43.COMMUNITY TAX CERTIFICATE NO. ISSUED ATISSUED ON (mm/dd/yyyy)DATE ACCOMPLISHEDSIGNATURE (Sign inside the box)  RIGHT THUMBMARK FIRST NAME MIDDLE NAME / / | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | GSIS ID NO.|Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal?COLLEGE>VII. TRAINING PROGRAMS (Start from the most recent training.)FATHER'S SURNAME27. 28.SPOUSE'S SURNAMEPHOTO%SCHOLARSHIP/ ACADEMIC HONORS RECEIVEDDATE OF BIRTH (mm/dd/yyyy)VPrint legibly. Mark appropriate boxes q with "P" and use separate sheet if necessary.'"(/!0TEL. NO.DDEGREE COURSE (Write in full) 16. RESIDENTIAL ADDRESS17. TELEPHONE NO.18. PERMANENT ADDRESS19. TELEPHONE NO.20. E-MAIL ADDRESS (if any)21. CELLPHONE NO. (if any)22. AGENCY EMPLOYEE NO.23. TIN ZIP CODE 'a. Have you ever been formally charged?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 items:I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust that this information shall remain confidential.a.b.)Are you a member of any indigenous group?a. Are you differently abled?b. Are you a solo parent?c. SSS NO.MOTHER'S MAIDEN NAME26. ;b. Have you ever been guilty of any administrative offense?Within the fourth degree (for Local Government Employees): appointing authority or recommending authority where you will be appointed?If YES, give details: _____________________________________ _____________________________________ _____________________________________If YES, give details: _____________________________________ _____________________________________ _____________________________________XIf YES, give details: ________________________________ ________________________________,If YES, please specify: ____________________(to be filled up by CSC) / / / / / / / /GAre you related by consanguinity or affinity to any of the following : NON-ACADEMIC DISTINCTIONS / RECOGNITION: (Write in full)MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full)BTITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write in full)INCLUSIVE DATES (mm/dd/yyyy)INCLUSIVE DATES OF ATTENDANCE (mm/dd/yyyy)NAME & ADDRESS OF ORGANIZATION (Write in full)(CS FORM 212 (Revised 2005), Page 4 of 4( CS FORM 212 (Revised 2005), Page 3 of 4'CS FORM 212 (Revised 2005), Page 2 of 4CS FORM 212 (Revised 2005)125. 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