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 PASCUA
NAME EXTENSION (JR., SR)
FIRST NAME JAYSON MARC

MIDDLE NAME MALLARI

3. DATE OF BIRTH
(mm/dd/yyyy) 10/10/1994 16. CITIZENSHIP

4. PLACE OF BIRTH ESTIPONA, PURA, TARLAC If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX

17. RESIDENTIAL ADDRESS

6 CIVIL STATUS
House/Block/Lot No. Street
MUNICIPAL ROAD
Subdivision/Village Barangay
ESTIPONA
7. HEIGHT (m) 166 CM
City/Municipality Province
8. WEIGHT (kg) 60 KILOS ZIP CODE PURA, TARLAC

18. PERMANENT ADDRESS

9. BLOOD TYPE
House/Block/Lot No. Street
MUNICIPAL ROAD
10. GSIS ID NO.
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1212-6744-0643 ESTIPONA

City/Municipality Province

12. PHILHEALTH NO. 0725-1470-4407 ZIP CODE 2312 PURA, TARLAC

13. SSS NO. 34-9211681-3 19. TELEPHONE NO.

14. TIN NO. 20. MOBILE NO. 09633213735

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) jaysonmallaripascua@gmail.com

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME PASCUA

NAME EXTENSION (JR., SR)
FIRST NAME CARLOS

MIDDLE NAME SIMON

25. MOTHER'S MAIDEN NAME MALLARI

SURNAME PASCUA

FIRST NAME OFELIA

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

ELEMENTARY ESTIPONA ELEMENTARY SCHOOL 6/7/2001 3/28/2007 MARCH

BEST
SECONDARY
VOCATIONAL / ESTIPONA HIGH SCHOOL 6/5/2008 3/29/2012 3/29/2012
STUDENT

TRADE
BACHELOR OF SECONDARY EDUCATION
COURSE
COLLEGE CIT COLLEGES OF PANIQUI FOUNDATION INC.
MAJOR IN SOCIAL STUDIES
5/11/2015 4/15/2019 4/15/2019

GRADUATE STUDIES

(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 PROFESSIONAL CITY OF PINES NATIONAL HIGH SCHOOL
76.2 9/29/2019 1829303 10/10/2023
TEACHERS (BAGUIO)

(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 SERVICE
28. INCLUSIVE DATES SALARY/ JOB/ PAY
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
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To (Y/ N)

N/A
 (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

N/A

(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) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

recieving and responding to workplace communication 10/30/2020 11/1/2020 TESDA ONLINE TRAINING

solar light night assembly 11/1/2020 11/1/2020 TESDA ONLINE TRAINING

INSTALLING AND CONFIGURING COMPUTER SYSTEM 10/14/2020 10/31/2020 TESDA ONLINE TRAINING

MAINTAINING COMPUTER SYSTEMs AND NETWORKs 10/14/2020 10/14/2020 TESDA ONLINE TRAINING

SKILLS TRAINING SERIES/PHOTO EDITING AND ILLUSTRATION USING KRITA (WEBINAR) 10/29/2020 10/29/2020 KAAGAPAY TEACHERS SUPPORT

LEADERSHIP SKILLS ( WEBINAR) 10/18/2020 10/18/2020 INDIAN YUOTH DEVELOPMENT SKILLS

The World of Modularization: Tips on Motivating SHS Students in Modular

10/13/2020 10/13/2020 vibal group
Distance Learning (WEBINAR)

Strategies for Promoting Literacy and Numeracy (WEBINAR) 10/14/2020 10/14/2020 vibal group

Research-Based Knowledge and Principles of Teaching and Learning (WEBINAR) 10/13/2020 10/13/202 VIBAL GROUP

Mother Tongue, Filipino, and English in Teaching and LearninG (WEBINAR) 10/15/2020 10/15/202 Vibal group

Content Knowledge: Its Application Within and Across Curriculum Areas (WEBINAR) 10/12/2020 10/12/2020 VIBAL GROUO

Communication Strategies for Online Classrooms (WEBINAR) 10/16/2020 10/16/2020 VIBAL GROUP

Performance-based Learning and Assessment for Deeper Learning (V-SMART

10/16/2020 10/16/2020 VIBAL GROUP
COURSEWARE)
Interactive Assessment Tools: Utilizing Digital Platforms to Evaluate (V-SMART
0/18/2020 10/18/2020 VIBAL SMART COURSEWARE
COURSEWARE)
Into the Flow: Fostering Creativity and Intrinsic Motivation with
10/17/2020 10/17/2020 VIBAL SMART COURSEWARE
Students in Distance Learning (V-SMART COURSEWARE)

(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 in
(Write in full)
full)

COMPUTER LITERATE
HONEST AND DEDICATED TO THE WORK
GIVEN
FLEXIBLE AT ANY TASK

(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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
________________________________

35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court?
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?
If YES, give details:
________________________________
________________________________
37. 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 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
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before 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?
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?
If YES, please specify:
b. Are you a person with disability?
If YES, please specify ID No:
c. Are you a solo parent?
If YES, please specify ID No:

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

ID picture taken within

NAME ADDRESS TEL. NO.
the last 6 months
3.5 cm. X 4.5 cm
CHARITO C. RAMILO ESTIPONA, PURA, TARLAC (passport size)

With full and handwritten

FRANCISCA C. MILLO PANIQUI, TARLAC 0920 431 3728 name tag and signature over
printed name

Computer generated
ANDREA B. MILLO ESTIPONA, PURA, TARLAC 9750849811 or photocopied picture
is not acceptable
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and
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 filing of PHOTO
administrative/criminal case/s against me.

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.) JAYSON MARC M. PASCUA
PLEASE INDICATE ID Number and Date of Issuance
Government Issued ID: SSS
ID/License/Passport No.: 34-9211681-3
Signature (Sign inside the box)

Date/Place of Issuance: 02/04/2020 -1:15 PM ( TARLAC 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