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CS FORM 212 (Revised 2005)
PERSONAL DATA SHEET
Print legibly. Mark appropriate boes !it" and #se separate s"eet
i$ ne%essary
I. PERSONAL INFORMATION
2. S&R'M
A * S * U * N * C * I * O * N * * * * * * * * * * * *F*RS+ 'M R
* O * N * E * L * * * * * * * * * * * * * * *
M*,,- 'M S * A * Y * A * B * O * C * * * * . 'M /+'S*O' (e.g. r.
Sr.) . ,+ OF 3*R+4 (6dd6yyyy) 01 6 02 6 1772 18. RS*,'+*- ,,RSS
9*P CO,
1:. +-P4O' 'O.
3lk. ; -ot 50 Sta. Moni%a 3rgy. CaayaMariveles 3ataan
5. P-C OF 3*R+4 3alanga 3ataan
8. S/ Male Feale
:. C*
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:. a. 4ave yo# ever been $orally %"argedJ
b. 4ave yo# ever been g#ilty o$ any adinistrative o$$enseJ
AS*$ AS ?ive detailsH
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
K
AS*$ AS ?ive
detailsH>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>;.
4ave yo# ever been %onvi%ted o$ any %rie or violation o$ any la!
de%ree ordinan%e or reg#lations by any Co#rt or trib#nalJ AS
*$ AS ?ive
detailsH>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
7. 4ave yo# ever been separated $ro t"e servi%e in any o$ t"e
$ollo!ing odesH resignation retireentdropped $ro t"e rolls disissal
terination end o$ ter $inis"ed %ontra%t =O- or p"ased o#t in
t"e
p#bli% or private se%torJ
AS*$ AS ?ive
detailsH>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
0. 4ave yo# ever been a %andidate in a national or lo%al
ele%tion (e%ept 3arangay ele%tionJ)
AS
*$ AS ?ive
detailsH>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
1. P#rs#ant toH (a) *ndigeno#s People@s %t (R ;:1)I Magna Carta
$or ,isabled Persons (R :2::)I and L Solo Parents =el$are %t o$
2000 (R ;7:2) please ans!er t"e $ollo!ing itesH
a. re yo# a eber o$ any indigeno#s gro#pJ
b. re yo# di$$erently abledJ
%. re yo# a solo parentJ
AS*$ AS please spe%i$yH
>>>>>>>>>>>>>>>>>>>>>>>>
AS*$ AS please spe%i$yH
>>>>>>>>>>>>>>>>>>>>>>>>
AS*$ AS please spe%i$yH
>>>>>>>>>>>>>>>>>>>>>>>>
2. RFR'CS (Person not related by %onsang#inity or a$$inity to
appli%ant 6 appointee)
P4O+O
'M ,,RSS +-. 'O.
ngelo R. 3asilio Mariveles 3ataan 070;;1108
. * de%lare #nder oat" t"at t"is Personal ,ata S"eet "as been
a%%oplis" by e and is a tr#e %orre%t and %oplete stateent p#rs#ant
to t"e provisions o$ pertinent la!s r#les and reg#lations o$ t"e
Rep#bli% o$ t"e P"ilippines.
* also a#t"oriGe t"e agen%y "ead 6 a#t"oriGed representative to
veri$y 6 validate t"e %ontents state "erein. * tr#st t"at t"is
in$oration s"all reain %on$idential.
COMMUNITY TAX CERTIFICATE NO
Mariveles 3ataanISSUED AT S*?'+&R (Sign inside t"e bo)
ISSUED ON ((mm//!!!!) ,+ CCOMP-*S4, R*?4+ +4&M3MR
CS FORM 212 (Revised 2005) Page o$ /"rr
"n# "orm $%$
*, pi%t#re taken !it"int"e last 8 ont"s.5 %. .5 %.(passport
siGe)
Cop#ter generatedor ero %opy o$ pi%t#re
is not a%%eptable
