From To NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

From to na na na na na na na na na na na na na na na

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From To N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A D N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A (Continue on separate sheet if necessary) VIII. OTHER INFORMATION 31. SPECIAL SKILLS and HOBBIES 32. N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A (Continue on separate sheet if necessary) SIGNATURE DATE 11/07/2017 CS FORM 212 (Revised 2017), Page 3 of 4 NAME & ADDRESS OF ORGANIZATION (Write in full) INCLUSIVE DATES (mm/dd/yyyy) NUMBER OF HOURS VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED (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) 3 3 . MEMBERSHIP IN ASSOCIATION/ORGANIZ ATION (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? Date Filed: Status of Case/s: 36. 37. 38.If YES, give details:If 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. 42. PHOTO Government Issued ID/License/Passport Signature (Sign inside the box) Date/Place of Issuan Date Accomplished D AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indica Person Administering Oath CS FORM 212 (Revised 2017), Page 4 of 4
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