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(Continue on separate sheet if necessary)
VIII.
OTHER INFORMATION
31.
SPECIAL SKILLS and HOBBIES
32.
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(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)

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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