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(Continue on separate sheet if necessary)SIGNATUREDATECS FORM 212 (Revised 2017), Page 3 of 4
34.Bureau or Department where you will be apppointed,a. within the third degree?35.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.NAMEADDRESSTEL. NO.42.PHOTOGovernment Issued ID/License/Passport NSignature (Sign inside the box)Date/Place of IssuanDate AccomplishedRight ThumbmarkAre you related by consanguinity or affinity to the appointing or recommending authority, or to thechief 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: ________________________________ a. Have you ever been found guilty of any administrative offense?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?If YES, give details: ________________________________ Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in the public or private sector?If YES, give details: ________________________________ a. Have you ever been a candidate in a national or local election held within the last year (except Barangay election)?
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- Family name, surname, Jr.