CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misinterpretation 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
Y SURNAME VICENCIO
NAME EXTENSION (JR., SR)
FIRST NAME JIERSON

MIDDLE NAME DEPUNO

3. DATE OF BIRTH
(mm/dd/yyyy) 10/21/1963 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by by
✘
birth naturalization
4. PLACE OF BIRTH ANTIQUE If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS Mahogany St.

Widowed Separate House/Block/Lot No. Street

St. Joseph Brgy. Balabag
Other/s: d Subdivision/Village Barangay
Pavia ILOILO
7. HEIGHT (m) 1.61 M
City/Municipality Province
8. WEIGHT (kg) 50 kg ZIP CODE 5000
18. PERMANENT ADDRESS Mahogany St.
9. BLOOD TYPE O'
House/Block/Lot No. Street
St. Joseph Brgy. Balabag
10. GSIS ID NO. 2002752405
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1580-0016-6681

Pavia ILOILO
City/Municipality Province
12. PHILHEALTH NO. 11-000034760-4 ZIP CODE 5000

13. SSS NO. 07-1255862-0 19. TELEPHONE NO.

14. TIN NO. 134-365-941 20. MOBILE NO. 09465409926

15. AGENCY EMPLOYEE NO.
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME
FIRST NAME
JNHS F12-0069 21. E-MAIL ADDRESS (if any) jiersonvicencio@deped.gov.ph
VICENCIO 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
ANGIE

MIDDLE NAME LASTUA

OCCUPATION Housewife

EMPLOYER/BUSINESS NAME none

BUSINESS ADDRESS none

TELEPHONE NO. 09292070352'

24. FATHER'S SURNAME VICENCIO (Deceased)

NAME EXTENSION (JR., SR)
FIRST NAME EMENIANO

MIDDLE NAME ALMONTE

25. MOTHER'S MAIDEN NAME DEPUNO (Deceased)

SURNAME VICENCIO

FIRST NAME ROSITA

MIDDLE NAME AMBAY (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
UNITS ACADEMIC
LEVEL (Write in full) EARNED
GRADUATED
HONORS
(Write in full) (if not RECEIVED
From To
graduated)
ELEMENTARY LIBERTAD CENTRAL SCHOOL PRIMARY EDUCATION 1971' 1977' 1976-77
VOCATIONAL / LIBERTAD NATIONAL VOCATIONAL
SECONDARY
SCHOOL
SECONDARY EDUCATION 1977' 1981' 1980-81

Electrical Installation Maintenance NCII TESDA NC II 6/15/2015 12/5/2015 562 hrs 2015
ILOILO SCIENCE AND TECHNOLOGY -
COLLEGE TRADE BSIE (Electricity) 1982' 1986' 1985-86
COURSE UNIVERSITY
ILOILO SCIENCE AND TECHNOLOGY -
GRADUATE STUDIES
UNIVERSITY
MSEI ( Educ'l Management) 21 units
(Continue on separate sheet if necessary)

SIGNATURE DATE February 05,2020

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

Professional Board Examination for Teachers 75.43 %' 10/26/1986 Iloilo City 563546 5/7/1987
REGISTERED MASTER ELECTRICIAN EXAMINATION
(PRC)
70.00%' 5/21/1988 Iloilo City 12627 9/14/1988

(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/ SERVICE
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY PAY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To
(Y/ N)
1/1/2019 to date Master Teacher I DepEd ( Jaro Nat'l High School) 41,650.00' Permanent Yes

1/1/2018 12/31/2018 Master Teacher I DepEd ( Jaro Nat'l High School) 39,007.00' Permanent Yes

4/2/2017 12/31/2017 Master Teacher I DepEd ( Jaro Nat'l High School) 36,532.00' Permanent Yes

4/2/2017 12/31/2015 Master Teacher I DepEd ( Jaro Nat'l High School) 36,532.00' Permanent Yes

1/1/2017 4/1/2017 Master Teacher I DepEd ( Jaro Nat'l High School) 36,111.00' Permanent Yes

1/1/2016 12/31/2016 Master Teacher I DepEd ( Jaro Nat'l High School) 33,831.00' Permanent Yes

4/2/2014 12/31/2015 Master Teacher I DepEd ( Jaro Nat'l High School) 31,696.00' Permanent Yes

6/1/2012 4/1/2014 Master Teacher I DepEd ( Jaro Nat'l High School) 31,351.00' Permanent Yes

6/1/2011 5/31/2012 Master Teacher I DepEd ( Jaro Nat'l High School) 28,305.00' Permanent Yes

4/1/2011 5/31/2001 Master Teacher I DepEd ( Jaro Nat'l High School) 25,259.00' Permanent Yes

6/24/2010 3/31/2011 Teacher I DepEd ( Jaro Nat'l High School) 17,237.00' Permanent Yes

7/1/2009 6/23/2010 Teacher I DepEd ( Jaro Nat'l High School) 16,011.00' Permanent Yes

6/18/2009 6/30/2009 Teacher I DepEd ( Jaro Nat'l High School) 13,948.00' Permanent Yes

7/1/2007 6/30/2008 Teacher I DepEd ( Jaro Nat'l High School) 13,608.00' Permanent Yes

6/18/2006 6/30/2007 Teacher I DepEd ( Jaro Nat'l High School) 12371.00 Permanent Yes

6/18/2003 6/17/2006 Teacher I DepEd ( Jaro Nat'l High School) 11,246.00' Permanent Yes

7/1/2001 6/17/2003 Teacher I DepEd ( Jaro Nat'l High School) 10,971.00' Permanent Yes

6/18/2000 6/30/2001 Teacher I DepEd ( Jaro Nat'l High School) 10,794.00' Permanent Yes

1/1/2000 6/17/2000 Teacher I DepEd ( Jaro Nat'l High School) 10,194.00' Permanent Yes

11/1/1997 12/31/1999 Teacher I DepEd ( Jaro Nat'l High School) 16162.00' Permanent Yes

6/18/1997 6/17/1997 Teacher I DepEd ( Jaro Nat'l High School) 9,041.00' Permanent Yes

1/1/1996 12/31/1996 Teacher I DepEd ( Jaro Nat'l High School) 7,558.00' Permanent Yes

1/1/1995 __ Teacher I DepEd ( Jaro Nat'l High School) 7,433.00' Permanent Yes

1/1/1994 12/31/1994 Teacher I DepEd ( Jaro Nat'l High School) 6,044.00' Permanent Yes
Reg.
6/17/1991 12/31/1993 Reg. Substitute DepEd ( Jaro Nat'l High School) 4,985.00' Yes
Substitute
Reg.
10/28/1990 3/30/1991 Reg. Substitute DepEd ( Jaro Nat'l High School) 3902.00' Yes
Substitute
Reg.
8/1/1990 10/27/1990 Reg. Substitute DepEd ( Jaro Nat'l High School) 3102.00 Yes
Substitute

(Continue on separate sheet if necessary)

SIGNATURE DATE February 05,2020

CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (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
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) From To Technical/etc)

School Based In-Service Training 10/21/2019' 10/25/2019 40hrs Technical DepEd (Jaro National High School)
Gender and Development Program on RA11036 Mental
10/18/2019' 10/19/2019 16hrs Technical DepEd (Jaro National High School)
Health
Division In-Service Training (INSET) 5/27/2019 5/29/2019 24hrs Technical DepEd (Division of Iloilo City)

School Based In-Service Training 5/30/2019 5/31/2019 16hrs Technical DepEd (Jaro National High School)

Division In-Service Training (INSET) 2018 10/22/2018 10/24/2018 24hrs Technical DepEd (Division of Iloilo City)

School - Based Roll-out on the adoption and

Implementation of the Philippine Standards for Teachers
9/20/2018 9/21/2018 16hrs Technical DepEd (Jaro National High School)
(PPST) and Results- Based Performance Management
System (RPMS) Manual.

Rights and Privileges of Senior Citizen as provided for by

7432 as mended by RA 9994 and the Laws and 3/16/2018 3/16/2018 8hrs Technical DepEd (Jaro National High School)
Mandates for Person with Disabilities

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

(Continue on separate sheet if necessary)

SIGNATURE DATE February 05,2020

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 by any court or tribunal?
YES ✘ NO
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 If YES, give details:
phased 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
YES ✘ NO
(except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
the last 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
Mr. JERRY LEGO DVISION OF ILOILO CITY 336-92-73 3.5 cm. X 4.5 cm
(passport size)

Ms. ZENAIDA SILVEDERIO ALTA TRIA JARO, ILOILO CITY 508-21-56 With full and handwritten
name tag and signature over
printed name
Hon. MARRIETA ORLEANS CUARTERO JARO, ILOILO CITY 09482731700
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied picture
is not acceptable
complete 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 PHOTO
filing of administrative/criminal case/s 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: BIR TIN

ID/License/Passport No.: 134-365-941

Signature (Sign inside the box)
February 05,2020
Date/Place of Issuance:
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this February 05,2020, affiant exhibiting his/her validly issued government ID as indicated above.

ERNESTO F. SERVILLION, JR., CESO V

Assistant Schools Division Superintentdent
Person Administering Oath

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