personal data capsule sheet(2007)

Form No. PIS-02

PERSONNEL DATA CAPSULE SHEET

BASIC PERSONAL DATA

TIN NAME EXTENSION (e.g. Jr., Sr.)

SURNAME NICK NAME

FIRST NAME

MIDDLE NAME PLACE OF BIRTH

SEX

CIVIL STATUSCITIZENSHIP

HEIGHT (m)

WEIGHT (kg) PHILHEALTH NO.

BLOOD TYPE SSS NO.

RELIGION PERSONAL E-MAIL ADDRESS

GSIS ID NO. OFFICIAL E-MAIL ADDRESS

GSIS POLICY NO. CELLPHONE NO. (if any)

GSIS BUSINESS PARTNER NO. AGENCY EMPLOYEE NO.

PAG-IBIG ID NO. ATMCURRENT ADDRESS MUNICIPALITY/CITY/PROVINCE ZIP CODE TELEPHONE NO.

PROVINCIAL ADDRESS MUNICIPALITY/CITY/PROVINCE ZIP CODE TELEPHONE NO.

SPOUSE'S SURNAMEPLACE OF BIRTH

FIRST NAME

MIDDLE NAME

OCCUPATION

NAME OF OFFICE

OFFICE ADDRESS

FATHER'S SURNAME

FIRST NAME

MIDDLE NAME

PLACE OF BIRTH

DECEASED

MOTHER'S MAIDEN NAME

FIRST NAME

MIDDLE NAME

PLACE OF BIRTH

DECEASED

CURRENT EMPLOYMENT

NAME OF OFFICE/ DEPARTMENT OLD PLANTILLA POSITION TITLE NEW PLANTILLA POSITION TITLE EFFECTIVITY DATE

PRESENT PLACE OF ASSIGNMENT DESIGNATION KEY OFFICIAL LEGAL BASIS OF PAYMENT EFFECTIVITY DATE

STEP INCREMENT AUTHORIZED SALARY ACTUAL SALARY SALARY BASIS LAST PROMOTION (mm/dd/yyyy) WITH GAP IN GOV'T SERVICE

STATUS OF APPOINTMENT CATEGORY OF SERVICE LEVEL OF POSITION NATURE OF WORK EMPLOYEE STATUS PERSONNEL ACTION

DATE OF BIRTH (mm/dd/yyyy)

Congressional District (1st, 2nd..)

Congressional District (1st, 2nd..)

NAME OF CHILD (Write full name and list all)

DATE OF BIRTH (mm/dd/yyyy)

FIRST DAY IN GOV'T SERVICE (mm/dd/yyyy)

Annulled Others, specify ___________

Single Married

Widowed

Separated

Male Female

DAILY MONTHLY

EXECUTIVE LEVEL

DIVISION CHIEF LEVEL

OTHER SUPERVISORY LEVEL

NON-SUPERVISORY LEVEL

KEY POSITION

ADMIN

TECHNICAL

SUPPORT TO TECHNICAL

FIRST LEVEL

SECOND LEVEL

THIRD LEVEL

PERMANENT

TEMPORARY

PRESIDENTIAL APPOINTEE

CASUAL

CONTRACTUAL - PS

ORIGINAL APPOINTMENT

PROMOTION

TRANSFER

SALARY INCREASECHANGE IN APPOINTMENT STATUS

RECLASSIFICATION

REINSTATEMENT

Revised 2010

ACTIVE ORIGINAL STATION

ACTIVE DETAILED

DISMISSED

ACTIVE STUDY/ SCHOLARSHIP LEAVE

RESIGNED

RETIRED

SUSPENDED

READ THIS FIRST !1. PRINT ALL ANSWERS CLEARLY. Typed answers are preferred but not required.2. For multiple choice items, CHECK THE BOX that corresponds to your answer.3. DO NOT WRITE anything on the "CURRENT EMPLOYMENT" portion. These items are for internal use and will be filled up by the Personnel Division.4. USE EXTRA BLANK SHEET OF PAPER if necessary but please follow the corresponding format.

Recent Photo

NOTE TO EMPLOYEE: DO NOT WRITE ANYTHING ON THIS PORTION. THIS SECTION IS TO BE FILLED UP BY THE PERSONNEL OFFICE

(Number, Street, Subdivision)

(Number, Street, Subdivision)

(mm/dd/yyyy)

YES NO

(mm/dd/yyyy)

YESNO

CONTRACTUAL - 29

YES NO

YES NO

PIS-02(Revised 2010), Page 1 of 4

CO-TERMINUS

REINSTATEMENT

RE-EMPLOYMENT

DISMISSED

DECEASED

EDUCATIONAL BACKGROUND

LEVELINCLUSIVE DATES OF ATTENDANCE

From To

ELEMENTARY

SECONDARY

COLLEGE

GRADUATE STUDIES

CIVIL SERVICE ELIGIBILITY

RATING PLACE OF EXAMINATION / CONFERMENT

LICENSE (if applicable)

NUMBERDATE OF RELEASE

WORK EXPERIENCE (Include private employment. Start from your current work)

INCLUSIVE DATES (mm/dd/yyyy)MONTHLY SALARY

From To

PIS-02(Revised 2010), Page 2 of 4

NAME OF SCHOOL

(Write in full)

DEGREE COURSE (Write in full)

YEAR GRADUATED

(if graduated)

HIGHEST GRADE/ LEVEL/ UNITS EARNED

(if not graduated)

SCHOLARSHIP/ ACADEMIC HONORS

RECEIVED

VOCATIONAL /

TRADE COURSE

CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEE

DATE OF EXAMINATION / CONFERMENT

POSITION TITLE (Write in full)

DEPARTMENT / AGENCY / OFFICE / COMPANY

(Write in full)

SALARY GRADE & STEP INCREMENT (Format "00-

0")

STATUS OF APPOINTMENT

GOV'T SERVICE

(Yes / No)

VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

From To

TRAINING PROGRAMS (Start from the most recent training.)

From To

OTHER INFORMATION

SPECIAL SKILLS / HOBBIES

PIS-02(Revised 2010), Page 3 of 4

NAME & ADDRESS OF ORGANIZATION (Write in full)

INCLUSIVE DATES

(mm/dd/yyyy) NUMBER OF HOURS

TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write in full)

INCLUSIVE DATES OF ATTENDANCE

(mm/dd/yyyy) NUMBER OF HOURS

CONDUCTED/ SPONSORED BY (Write in full)

NON-ACADEMIC DISTINCTIONS / RECOGNITION (Write in full)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write

in full)

Are you related by consanguinity or affinity to any of the following :

a.

b.

a. Have you ever been formally charged?

b. Have you ever been guilty of any administrative offense?

Have you ever been a candidate in a national or local election (except Barangay election)?

a. Are you a member of any indigenous group?If YES, please specify: ____________________

b. Are you differently abled?If YES, please specify: ____________________

c. Are you a solo parent?If YES, please specify: ____________________

REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)

NAME ADDRESS TEL. NO.

PHOTO

COMMUNITY TAX CERTIFICATE NO.

ISSUED AT SIGNATURE (Sign inside the box)

ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

PIS-02(Revised 2010), Page 4 of 4

Within the third degree (for National Government Employees): appointing authority, recommending authority, chief of office/bureau/department or person who has immediate supervision over you in the Office, Bureau or Department where you will be appointed?

If YES, give details: _____________________________________ _____________________________________ _____________________________________

Within the fourth degree (for Local Government Employees): appointing authority or recommending authority where you will be appointed? If YES, give details:

_____________________________________ _____________________________________ _____________________________________

If YES, give details: ________________________________ ________________________________

If YES, give details: ________________________________ ________________________________

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, AWOL or phased out, in the public or private sector?

If YES, give details: ________________________________ ________________________________

If YES, give details: ________________________________ ________________________________

Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA 7277); and (c) Solo Parents Welfare Act of 2000 (RA 8972), please answer the following items:

I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines.

I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust that this information shall remain confidential.

ID picture taken within the last 6 months3.5 cm. X 4.5 cm(passport size)

Computer generated or xerox copy of picture

is not acceptable

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO