Attendance mmddyyyy number of hours type of ld

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)

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.
42.
PHOTO
Government Issued
ID/License/Passport
Signature (Sign inside the box)
Date/Place of Issuan
Date Accomplished Right Thumbmark
AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indi
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?
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?