DRIVING NA Continue on separate sheet if necessary SIGNATURE DATE CS FORM 212

Driving na continue on separate sheet if necessary

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DRIVING N/A (Continue on separate sheet if necessary) SIGNATURE DATE CS FORM 212 (Revised 2017), Page 3 of 4 NAME & ADDRESS OF ORGANIZATION (Write in full) INCLUSIVE DATES (mm/dd/yyyy) NUMBER OF HOURS (Start from the most recent L&D/training program and include only the relevant L&D/training taken for the last five (5) years for Division Chief/Executive/Managerial positions) TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS (Write in full) INCLUSIVE DATES OF ATTENDANCE (mm/dd/yyyy) NUMBER OF HOURS Type of LD ( Managerial/ Supervisory/ Technical/etc) CONDUCTED/ SPONSORED BY (Write in full) NON-ACADEMIC DISTINCTIONS / RECOGNITION (Write in full) MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full)
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34. Bureau or Department where you will be apppointed, a. within the third degree? 35. a. Have you ever been found guilty of any administrative offense? atus of Case/s: 36. 37. 38. YES, give details: YES, give details: 39. If YES, give details (country): 40. Are you a member of any indigenous group? If YES, please specify: Are you a person with disability? If YES, please specify ID No: Are you a solo parent? If YES, please specify ID No: 41. NAME ADDRESS TEL. NO. JAVIER HIZON JR PARIAN, MEXICO, PAMPANGA ELEN QUIAMBAO PARIAN, MEXICO, PAMPANGA MANUEL GOMEZ PARIAN, MEXICO, PAMPANGA 42. PHOTO Government Issued I DRIVER'S LICENSE ID/License/Passport N CIO-97-135-907 Signature (Sign inside the box) Date/Place of Issuan 04/2018, CSFP Date Accomplished Right Thumbmark AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as ind Person Administering Oath CS FORM 212 (Revised 2017), Page 4 of 4 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, b. within the fourth degree (for Local Government Unit - Career Employees)? If YES, give details: ________________________________ If YES, give details: ________________________________ b. Have you been criminally charged before any court? If YES, give details: ________________________________ Filed: Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal?
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