CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misrepresentation made in the Personal Data Sheet and the Work Experience Sheet shall cause the filing of administrative/criminal case/s against the person
concerned.
READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.
Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE. 1. CS ID No. (Do not fill up. For CSC use only)

I. PERSONAL INFORMATION
2. SURNAME DELA CRUZ
NAME EXTENSION (JR., SR) JR.
FIRST NAME JUAN

MIDDLE NAME ABAD

3. DATE OF BIRTH
(mm/dd/yyyy) 01/01/2020 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH BIHIS, STA. TERESITA, BATANGAS If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

✘ Single Married 17. RESIDENTIAL ADDRESS 5 ILANG-ILANG ST.

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
Other/s: PRESTINE VILLAGE ANTIPOLO
Subdivision/Village Barangay
STA. TERESITA BATANGAS
7. HEIGHT (m) 1.524
City/Municipality Province
8. WEIGHT (kg) 50 ZIP CODE

18. PERMANENT ADDRESS 5 ILANG-ILANG ST.

9. BLOOD TYPE O
House/Block/Lot No. Street

10. GSIS ID NO. 2002111155 PRESTINE VILLAGE ANTIPOLO

STA. TERESITA BATANGAS

11. PAG-IBIG ID NO. 1212-1212-4444
City/Municipality Province

12. PHILHEALTH NO. 09-250044221-1 ZIP CODE 4204

13. SSS NO. 04-1336663-0 19. TELEPHONE NO. None

14. TIN NO. 441-926-511 20. MOBILE NO. 09991111122

15. AGENCY EMPLOYEE NO. 6734545 21. E-MAIL ADDRESS (if any) juan.delacruz@deped.gov.ph
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME DELA CRUZ 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME JUANA N/A JESS ABAD DELA CRUZ 02/01/2020

MIDDLE NAME ABEL

OCCUPATION TEACHER II

EMPLOYER/BUSINESS NAME DEPED-SHS WITHIN CALUMPANG ES

BUSINESS ADDRESS CALUMPANG WEST SAN LUIS BATANGAS

TELEPHONE NO. NONE

24. FATHER'S SURNAME DELA CRUZ

NAME EXTENSION (JR., SR)
FIRST NAME PEDRO SR.

MIDDLE NAME ANDRES

25. MOTHER'S MAIDEN NAME

SURNAME ABAD

FIRST NAME ANNA

MIDDLE NAME CRUZ (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL HIGHEST LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
BASIC EDUCATION/DEGREE/COURSE UNITS ACADEMIC
LEVEL (Write in GRADUATED
HONORS
(Write in full) EARNED
full) (if not graduated) RECEIVED
From To

VALEDICTO
ELEMENTARY SAMPAGA ELEMENTARY SCHOOL ELEMENTARY 1992 1998 N/A 1998
RIAN
WITH
SECONDARY
VOCATIONAL / SAMPAGA NATIONAL HIGH SCHOOL HIGH SCHOOL 1998 2002 N/A
HONORS

N/A N/A N/A N/A N/A N/A N/A

TRADE
COURSE BACHELOR OF SCIENCE IN SECONDARY
COLLEGE BATANGAS STATE UNIVERSITY
EDUCATION MAJOR IN ENGLISH
2002 2006

GRADUATE STUDIES GOLDEN AGTE COLLEGES MASTER OF ARTS IN EDUCATION 2006 2008

(Continue on separate sheet if necessary)

SIGNATURE DATE CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (if applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity

LICENSURE EXAMINATION FOR TEACHERS 78% 01/01/2010 LUCENA CITY BATANGAS 20200 02/02/2013

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experience sheet.
GOV'T
28. INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To
(Y/ N)
DEPARTMENT OF EDUCATION, SANTA
01/01/2020 Present TEACHER II 24,779.00 12-2 PERMANENT Y
TERESITA NATIONAL HIGH SCHOOL
DEPARTMENT OF EDUCATION, SANTA
01/01/2019 12/31/2019 TEACHER II 23,222.00 12-2 PERMANENT Y
TERESITA NATIONAL HIGH SCHOOL
DEPARTMENT OF EDUCATION, SANTA
01/01/2018 12/31/2018 TEACHER II 22,149.00 12-1 PERMANENT Y
TERESITA NATIONAL HIGH SCHOOL

(Continue on separate sheet if necessary)

SIGNATURE DATE CS FORM 212 (Revised 2017), Page 2 of 4

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
29. NAME & ADDRESS OF ORGANIZATION
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

(Continue on separate sheet if necessary)

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)
INCLUSIVE DATES OF
ATTENDANCE Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(Write in full) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To

DEPED SCHOOLS DIVISION OFFICE

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33. (Write
(Write in full)
in full)

(Continue on separate sheet if necessary)

SIGNATURE DATE CS FORM 212 (Revised 2017), Page 3 of 4

 34. 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,
Bureau or Department where you will be apppointed,
a. within the third degree? YES NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES NO
If YES, give details:
________________________________

35. a. Have you ever been found guilty of any administrative offense? YES NO
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court? YES NO
If YES, give details:
________________________________
Date Filed:
________________________________
Status of Case/s:

36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation NO
YES
by any court or tribunal?
If YES, give details:
________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation, YES NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased If YES, give details:
out (abolition) in the public or private sector? ________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
YES NO
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last YES NO
election to promote/actively campaign for a national or local candidate? If YES, give details:
39. Have you acquired the status of an immigrant or permanent resident of another country?
YES NO
If YES, give details (country):

40. 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:
a. Are you a member of any indigenous group? YES NO
If YES, please specify:
b. Are you a person with disability? YES NO
If YES, please specify ID No:
c. Are you a solo parent? YES NO
If YES, please specify ID No:

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

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten

name tag and signature over
printed name

Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete or photocopied picture
is not acceptable
statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. I
authorize the agency head / authorized representative to verify/validate the contents stated herein. I agree that any
misrepresentation made in this document and its attachments shall cause the filing of administrative/criminal case/s PHOTO
against me.

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of Issuance
Government Issued ID: PRC LICENSE

ID/License/Passport No.: 222222

Signature (Sign inside the box)

Date/Place of Issuance: 01/01/2020/LUCENA CITY

Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.

Person Administering Oath

CS FORM 212 (Revised 2017), Page 4 of 4