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
2. SURNAME GENECERA
NAME EXTENSION (JR., SR)
FIRST NAME JESSIE

MIDDLE NAME N/A

3. DATE OF BIRTH
(mm/dd/yyyy) 11/13/1994 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH GEN. SANTOS CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS PRK. RIVERSIDE

House/Block/Lot No. Street
Widowed
Separated PUNONG GRANDE
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 1.63 BANGA SOUTH COTABATO
City/Municipality Province
8. WEIGHT (kg) 65 ZIP CODE 9511

9. BLOOD TYPE O+
18. PERMANENT ADDRESS PRK. RIVERSIDE
House/Block/Lot No. Street

10. GSIS ID NO. 021-1956-6627-7 PUNONG GRANDE

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 12118789505 BANGA SOUTH COTABATO

City/Municipality Province

12. PHILHEALTH NO. 17-252723416-1 ZIP CODE 9511

13. SSS NO. 09-4175808-4 19. TELEPHONE NO. None

14. TIN NO. 493-697-930 20. MOBILE NO. 09477721985

15. AGENCY EMPLOYEE NO. 4927145 21. E-MAIL ADDRESS (if any) jessie.genecera@deped.gov.ph

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME ECHEVERE 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME JANE CHANDRIA GAIL E. GENECERA 11/23/2013

MIDDLE NAME DE FACTO WILHELM VONN E. GENECERA 9/11/2016

OCCUPATION HOUSEWIFE

EMPLOYER/BUSINESS NAME NONE

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME N/A

NAME EXTENSION (JR., SR)
FIRST NAME N/A

MIDDLE NAME N/A

25. MOTHER'S MAIDEN NAME

SURNAME GENECERA

FIRST NAME JENNIFER

MIDDLE NAME MONTALBAN (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL HIGHEST LEVEL/

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

ELEMENTARY NEW DUMANGAS ELEMENTARY SCHOOL ELEMENTARY 2001 2007 N/A 2007 None

NEW DUMANGAS NATIONAL HIGH

SECONDARY /
VOCATIONAL SECONDARY 2007 2011 N/A 2011 None
SCHOOL

None None N/A N/A N/A N/A None

TRADE
COURSE MINDANAO STATE UNIVERSITY - BACHELOR OF SECONDARY EDUCATION
COLLEGE
MAJOR IN BIOLOGY
2011 2016 N/A 2016 None
GENERAL SANTOS

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 TEACHERS 82.60 9/25/2016 GENERAL SANTOS CITY 1504472 11/13/2022

(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
SALARY/ JOB/ PAY SERVICE
28. INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
MONTHLY STATUS OF
(mm/dd/yyyy) (Write in full/Do not (Write in applicable)& STEP
SALARY (Format "00-0")/ APPOINTMENT
abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)
DEPARTMENT OF EDUCATION-NEW
05/25/2018 Present TEACHER I DUMANGAS NATIONAL HIGH SCHOOL
25,723 11-2 PERMANENT YES
MARVELOUS COLLEGE OF TECHNOLOGY CONTRACTUA
6/02/2017 04/06/2018 SENIOR HIGH SCHOOL FACULTY 7,530 N/A N
INCORPORATED L

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 18,2022 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

NONE NONE

(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

Seminar on Mental Health and Psychological Support for teachers and non-teaching
3/17/2021 3/17/2021 8 TECHNICAL Dep. Ed. New Dumangas National High School
personel

INTERNATIONAL TRAINING SERIES ON LEARNING AND INSTRUCTIONAL Southeast Asian Institute of Educational Training
3/8/2019 3/10/2019 24 TECHNICAL
TEACHING STYLES Incorporated
2018 DIVISION TEACHER INDUCTION PROGRAM FOR THE NEWLY
9/13/2018 9/14/2018 16 TECHNICAL Department of Education - South Cotabato
HIRED TEACHERS
THREE DAY LIVE-OUT DIVISION TRAINING ON BASIC ELEMENTS IN MUSIC AND
8/9/2018 8/11/2018 24 TECHNICAL Department of Education - South Cotabato
ARTS AND BASIC DANCE STEPS FOR SECONDARY MAPEH TEACHERS
Technical Educational and Skills Development
NATIONAL CERTIFICATE II IN COOKERY 9/7/2017 11/15/2017 316 TECHNICAL
Authority - Koronadal

(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)

CAN MANIPULATE BASIC COMPUTER USES NONE NONE

MICROSOFT OFFICE APPLICATION NONE NONE

(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
YES ✘ NO
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
LEONARD A. TRAVILLA EDWARDS, T'BOLI, SOUTH COTABATO 3.5 cm. X 4.5 cm
(passport size)

NESTOR A. RAGUINDIN TANTANGAN, SOUTH COTABATO With full and handwritten

name tag and signature over
printed name
RAMON E. DAGNAOS, JR. EDWARDS, T'BOLI, SOUTH COTABATO
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
ID/License/Passport No.: 1504472 Signature (Sign inside the box)
11/23/2018 - GENERAL SANTOS
Date/Place of Issuance:
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