Personal Data Sheet Page 4
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436.
Are you related by consanguinity or affinity to any of the following :
Yes / No
:
a.
Within the third degree (for National Government Employees):
appointing authority, recommending authority, chief of office/bureau/department or person who
If YES, give details:
has immediate supervision over you in the Office, Bureau or Department where you will be
_____________________________________
appointed?
_____________________________________
_____________________________________
b.
Within the fourth degree (for Local Government Employees):
Yes / No
:
appointing authority or recommending authority where you will be appointed?
If YES, give details:
_____________________________________
_____________________________________
_____________________________________
a. Have you ever been formally charged?
Yes / No
:
37
If YES, give details:
________________________________
________________________________
b. Have you ever been guilty of any administrative offense?
Yes / No
:
If YES, give details:
________________________________
________________________________
Have you ever been convicted of any crime or violation of any law, decree, ordinance or
Yes / No
:
38.
regulation by any court or tribunal?
If YES, give details:
________________________________
________________________________
Have you ever been separated from the service in any of the following modes: resignation,
39.
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract, AWOL or
Yes / No
:
phased out, in the public or private sector?
Have you ever been a candidate in a national or local election (except Barangay election)?
Yes / No
:
40.
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 8972), please answer the following items:
Yes / No
:
a.
Are you a member of any indigenous group?
If YES, please specify: ____________________
b.
Are you differently abled?
Yes / No
:
If YES, please specify: ____________________
Yes / No
:
c.
Are you a solo parent?
If YES, please specify: ____________________
REFERENCES
(Person not related by consanguinity or affinity to applicant / appointee)
42.
TEL. NO.
NAME
ADDRESS
ID picture taken within
the last 6 months
3.5 cm. X 4.5 cm
(passport size)
43.
I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and
Computer generated
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the
or xerox copy of picture
Philippines.
is not acceptable
I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust
that this information shall remain confidential.
PHOTO
COMMUNITY TAX CERTIFICATE NO.
SIGNATURE
(Sign inside the box)
ISSUED AT
DATE ACCOMPLISHED
ISSUED ON (mm/dd/yyyy)
RIGHT THUMBMARK
NEDA PDS Form Page 4 of 4
CS FORM 212 (Revised 2005)
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