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 JENNIEFER
NAME EXTENSION (JR., SR)
FIRST NAME MACA

MIDDLE NAME CEBALLOS

3. DATE OF BIRTH
(mm/dd/yyyy) 04/18/1998 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH BICUTAN TAGUIG,METRO MANILA If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS N/A N/A

Widowed House/Block/Lot No. Street

Separate
d PUROK KAMANTING MARAYA
Other/s:
Subdivision/village Barangay
VINCENZO SAGUN ZAMBOANGA DEL SUR
7. HEIGHT (m) 152CM
City/Municipality Province
8. WEIGHT (kg) 50KG ZIP CODE 7036

18. PERMANENT ADDRESS N/A N/A

9. BLOOD TYPE AB+
House/Block/Lot No. Street

10. GSIS ID NO. N/A PUROK KAMANTING MARAYA

Subdivision/village Barangay
11. PAG-IBIG ID NO. N/A
VINCENZO SAGUN ZAMBOANGA DEL SUR

12. PHILHEALTH NO. 142514272335 ZIP CODE City/Municipality Province

13. SSS NO. N/A 19. TELEPHONE NO. N/A

14. TIN NO. N/A 20. MOBILE NO. 09106271534

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME N/A

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

MIDDLE NAME N/A N/A N/A

OCCUPATION N/A N/A N/A

EMPLOYER/BUSINESS NAME N/A N/A N/A

BUSINESS ADDRESS N/A N/A N/A

TELEPHONE NO. N/A N/A N/A

24. FATHER'S SURNAME CEBALLOS N/A N/A

FIRST NAME MIGUEL

JR. N/A N/A

MIDDLE NAME SEDOMIA N/A N/A

25. MOTHER'S MAIDEN NAME

N/A N/A

SURNAME MACA N/A N/A

FIRST NAME SUSAN N/A N/A

MIDDLE NAME GENOVIA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY MARAYA ELEMENTARY SCHOOL PRIMARY EDUCATION 1/6/2004 03/20/2009 Graduated 2009 SALUTATORIAN

SECONDARY JUDGE EDMUNDO PINGA NATIONAL HIGH SCHOOL HIGH SCHOOL 5/6/2009 04/28/2014 Graduated 2014 WITH HONOR
VOCATIONAL /

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

TRADE
COURSE BACHELOR OF SECONDARY EDUCATION
COLLEGE JH CERILLES STATE COLLEGE MAJOR IN FILIPINO 06/25/2014 03/28/2018 Graduated 2018 N/A

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 10, 2024

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

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

LICENSURE EXAMINATION FOR TEACHERS 76.0 09/29/2019 PAGADIAN CITY 1814749 4/18/2025

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

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

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

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

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

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

(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
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY GRADE (if 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,VINCENZO SAGUN

5/10/2020 02/30/2021 BARANGAY PAID TEACHER DISTRICT 27000.00 N/A BARANGAY PAID N/A
DEPARTMENT OF EDUCATION,VINCENZO SAGUN LOCAL PAID
02/30/2021 1/3/2021 LOCAL PAID TEACHER DISTRICT N/A N/A TEACHER N/A
DEPARTMENT OF EDUCATION,VINCENZO SAGUN
01/032023 03/31/2020 PROVINCIAL PAID TEACHER DISTRICT N/A N/A PROVINCIAL PAID N/A
DEPARTMENT OF EDUCATION,VINCENZO SAGUN
2/10/2023 12/31/2023 PROVINCIAL PAID TEACHER DISTRICT N/A N/A PROVINCIAL PAID N/A
DEPARTMENT OF EDUCATION,VINCENZO SAGUN
08/24/2023 1/1/2024 PROVINCIAL PAID TEACHER DISTRICT N/A N/A PROVINCIAL PAID N/A

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

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

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

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

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

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

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

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

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

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

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

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

N/A N/A N/A N/A
(Continue on separate sheet if necessary)
N/A N/A N/A N/A

SIGNATURE DATE APRIL 10, 2024

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

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

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

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

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

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

N/A N/A N/A N/A 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
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE Type of LD
NUMBER OF HOURS
( Managerial/ CONDUCTED/ SPONSORED BY
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To
CLUSTER-5(INSET 2023)MIDYEAR REVIEW OF SCHOOL PPA'S&IPCRF CUM 2/6/2023 2/10/2023 40.0 N/A DEPARTMENT OF EDUCATION,DIVISION OF
PREPARATION OF INSTRUCTION MATERIALS & ALIGNED WITH MELCS ZAMBOANGA DEL SUR,VINCENZO SAGUN
TWO-DAY LIVE-OUTS DISTRICT SEMINAR ENHANCEMENT WORKSHOP ON CAMPUS 02/18/2023 02/19/2023 24.0 N/A DEPARTMENT OF EDUCATION,DIVISION OF
JOURNALISM FOR SPA'S JOURNALISM COORDINATORS AND STUDENT JOURNALISM ZAMBOANGA DEL SUR,VINCENZO SAGUN
DISTRICT PRESS CONFERENCE'' MAKATUTUHANANG IMPORMASYON,SANDIGAN NG 04/29/2023 04/30/2023 24.0 N/A DEPARTMENT OF EDUCATION,DIVISION OF
MAPAGPALAYANG PAMAMAHAYAG'' (COACH) ZAMBOANGA DEL SUR,VINCENZO SAGUN
SIMULTANEOUS DISTRICT CASCADING ON HIGHER ORDER THINKING SKILLS- DEPARTMENT OF EDUCATION,DIVISION OF
PROFESSIONAL LEARNING PACKAGE(HOTS-PLP) FOR SECONDARY SCHOOL HEADS 10/11/2023 12/11/2023 24.0 N/A ZAMBOANGA DEL SUR,VINCENZO SAGUN
AND TEACHERS
N/A N/A N/A N/A N/A
N/A
N/A N/A N/A N/A N/A
N/A
N/A N/A N/A N/A N/A
N/A
N/A N/A N/A N/A N/A N/A

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

N/A
N/A N/A N/A N/A N/A
N/A
N/A N/A N/A N/A N/A
N/A
N/A N/A N/A N/A N/A
N/A
N/A N/A N/A N/A N/A
N/A
N/A N/A N/A N/A N/A
N/A
N/A N/A N/A N/A N/A
N/A
N/A N/A N/A N/A N/A
N/A
(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

STRONG WORK ETHIC N/A N/A

GOOD TO HOLD TEMPER N/A N/A

DANCING N/A N/A

READING BOOKS N/A N/A

SINGING N/A N/A
COmputer Literacy

SIGNATURE DATE APRIL 10, 2024

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,
✘ NO
a. within the third degree? YES
✘ NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES

If YES, give details:

________________________________
N/A
✘ NO
YES
35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
✘ NO
YES N/A
________________________________

b. Have you been criminally charged before any court?

If YES, give details:
________________________________
✘ NO Date Filed: N/A
________________________________
YES
Status of Case/s: N/A
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:
________________________________
N/A
________________________________
✘ NO
37. Have you ever been separated from the service in any of the following modes: resignation, YES
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? NO
________________________________
✘
YES N/A
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? ✘ NO
YES
If YES, give details: N/A
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: N/A
39. Have you acquired the status of an immigrant or permanent resident of another country? ✘ NO
YES
If YES, give details (country):
✘ NO
YES N/A

Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons NO
YES(RA
40. ✘

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: N/A
b. Are you a person with disability?
If YES, please specify ID No: N/A
c. Are you a solo parent? N/A
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
SUNRISE VILLAGE TIGUMA PAGADIAN the last 6 months
DR.EUGENE B. PENALES CITY 3.5 cm. X 4.5 cm
(passport size)

RUEL M. FUERZAS SANTA MARIA PAGADIAN CITY With full and handwritten
name tag and signature over
printed name
DIOMEDES H. ROSALES Vincenzo Sagun Zamboanga del Sur
Computer generated
42. or photocopied picture
is not acceptable

PHOTO

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

ID/License/Passport No.: 1814749

Signature (Sign inside the box)
APRIL 10, 2024
Date/Place of Issuance: 04/18/2019
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