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    Nelia Z. Anguluan, PHD: Susan Marie P. Bartolome, PHD

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    Jesieca Bulauan
    This document contains a personal data sheet that collects information about an individual applying for a government position. It asks about the applicant's relationships within the hiring agency, any past administrative or criminal offenses, prior separations from government service, political activities, immigrant status in other countries, and references. The applicant declares that the information provided is true and correct and authorizes verification of the contents. They also agree that any misrepresentation could result in administrative or criminal charges against them.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Nelia Z. Anguluan, PHD: Susan Marie P. Bartolome, PHD

    Uploaded by

    Jesieca Bulauan
    42 views1 page
    This document contains a personal data sheet that collects information about an individual applying for a government position. It asks about the applicant's relationships within the hiring agency, any past administrative or criminal offenses, prior separations from government service, political activities, immigrant status in other countries, and references. The applicant declares that the information provided is true and correct and authorizes verification of the contents. They also agree that any misrepresentation could result in administrative or criminal charges against them.

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    This document contains a personal data sheet that collects information about an individual applying for a government position. It asks about the applicant's relationships within the hiring agency, any past administrative or criminal offenses, prior separations from government service, political activities, immigrant status in other countries, and references. The applicant declares that the information provided is true and correct and authorizes verification of the contents. They also agree that any misrepresentation could result in administrative or criminal charges against them.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    42 views1 page

    Nelia Z. Anguluan, PHD: Susan Marie P. Bartolome, PHD

    Uploaded by

    Jesieca Bulauan
    This document contains a personal data sheet that collects information about an individual applying for a government position. It asks about the applicant's relationships within the hiring agency, any past administrative or criminal offenses, prior separations from government service, political activities, immigrant status in other countries, and references. The applicant declares that the information provided is true and correct and authorizes verification of the contents. They also agree that any misrepresentation could result in administrative or criminal charges against them.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    34.

    Are you related by consanguinity or affinity to the appointing or recommending authority, or to the
    chief of bureau or office or to the person who has immediate supervision over you in the 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 regulation by YES NO
    any court or tribunal? If YES, give details:
    ________________________________

    37. Have you ever been separated from the service in any of the following modes: resignation, retirement, YES NO
    dropped from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in If YES, give details:
    the public or private sector?
    38. a. Have you ever been a candidate in a national or local election held within the last year (except YES NO
    Barangay election)? If YES, give details:
    b. Have you resigned from the government service during the three (3)-month period before the last YES NO
    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 items:
    a. Are you a member of any indigenous group? YES NO
    If YES, please specify: IBANAG
    b. Are you a person with disability? YES NO
    If YES, please specify ID No:
    c. Are you a solo parent? YES NO
    If YES, please specify ID No:

    41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

    NAME ADDRESS TEL. NO.


    ID picture taken within
    CATABAYUNGAN, CABAGAN, the last 6 months
    NELIA Z. ANGULUAN, PhD 9268942653 3.5 cm. X 4.5 cm
    ISABELA (passport size)

    JAINE Z. TARUN, PHD ANAO, CABAGAN, ISABELA 9363104247 With full and handwritten
    name tag and signature over
    printed name
    ANNAFUNAN, TUMAUINI
    MARICAR V. LIMBO 09175081310
    ISABELA Computer generated
    or photocopied picture
    42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete is not acceptable
    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 filing of administrative/criminal case/s PHOTO
    against me.

    Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)


    PLEASE INDICATE ID Number and Date of Issuance
    Government Issued ID: PRC

    ID/License/Passport No.: 1688958


    Signature (Sign inside the box)

    12/27/2018/TUGUEGARAO
    Date/Place of Issuance:
    CITY,CAGAYAN
    Date Accomplished Right Thumbmark

    SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.

    SUSAN MARIE P. BARTOLOME, PhD


    ADMINISTRATIVE OFFICER V

    Person Administering Oath


    CS FORM 212 (Revised 2017), Page 4 of 4

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