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 c
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.
I. PERSONAL INFORMATION
2. SURNAME DELA CRUZ

FIRST NAME MARY JANE

MIDDLE NAME ROMERO

3. DATE OF BIRTH
(mm/dd/yyyy) 05/25/1994 16. CITIZENSHIP
✘ Filipino

4. PLACE OF BIRTH CABANATUAN CITY, NUEVA ECIJA If holder of dual citizenship,

please indicate the details.

5. SEX Male ✘ Female

Single ✘ Married 17. RESIDENTIAL ADDRESS 700

6 CIVIL STATUS
Widowed Separated House/Block/Lot No.
Other/s: N/A
Subdivision/Village
7. HEIGHT (m) 1.50 m GUIMBA
City/Municipality
8. WEIGHT (kg) 55 kgs ZIP CODE 3115
18. PERMANENT ADDRESS N/A
9. BLOOD TYPE O
House/Block/Lot No.
N/A
10. GSIS ID NO. 20-0530505-6
Subdivision/Village
GUIMBA
11. PAG-IBIG ID NO. 1212-1076-8969
City/Municipality

12. PHILHEALTH NO. 21-025379013-4 ZIP CODE 3115

13. SSS NO. 02-3840302-6 19. TELEPHONE NO. N/A

14. TIN NO. 587-689-877 20. MOBILE NO. 0990-689-3937

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) janedelacruz@gmail.com

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME DELA CRUZ 23. NAME of CHILDREN (Write full name and list all)

FIRST NAME JUAN

NAME EXTENSION (JR., SR) SR JUAN R. DELA CRUZ, JR.

MIDDLE NAME PINEDA

OCCUPATION CIVIL ENGINEER

EMPLOYER/BUSINESS NAME DELA CRUZ-ROMERO CORPORATION

 BUSINESS ADDRESS MUCDOL, DIPACULAO, AURORA

TELEPHONE NO. N/A

24. FATHER'S SURNAME ROMERO

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

MIDDLE NAME CARPIO

25. MOTHER'S MAIDEN NAME

SURNAME JACOBA

FIRST NAME MYRA

MIDDLE NAME DE JESUS (Continue on separate she

III. EDUCATIONAL BACKGROUND

26. NAME OF SCHOOL PERIOD OF ATTENDANCE

BASIC EDUCATION/DEGREE/COURSE
LEVEL (Write in
(Write in full)
full)
From

ELEMENTARY CAVITE ELEMENTARY SCHOOL PRIMARY EDUCATION 2002

OUR LADY OF THE SACRED HEART

SECONDARY /
VOCATIONAL HIGH SCHOOL 2007
COLLEGE OF GUIMBA INC.

N/A
TRADE
COURSE
COLLEGE CENTRAL LUZON STATE UNIVERSITY
BACHELOR OF SCIENCE IN BUSINESS ADMINISTRATION
2011
MAJOR IN HUMAN RESOURCE DEVELOPMENT MANAGEMENT

MANUEL V. GALLEGO FOUNDATION, CERTIFICATE PROGRAM FOR TEACHER EDUCATION

COLLEGE (CPTE) 2019
COLLEGES, INC.
MASTER IN BUSINESS
GRADUATE STUDIES CENTRAL LUZON STATE UNIVERSITY 2017
ADMINISTRATION

NUEVA ECIJA UNIVERSITY OF SCIENCE DOCTOR OF PHILOSOPHY IN BUSINESS

GRADUATE STUDIES 2020
AND TECHNOLOGY ADMINISTRATION

(Continue on separate sheet if necessary)

SIGNATURE DATE

PDS v1 as of July 11, 2022

MJJRomero
HEET
filing of administrative/criminal case/s against the person

HE PDS FORM.
1. CS ID No. (Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

N/A

✘ Filipino Dual Citizenship

✘ by birth by naturalization
Pls. indicate country:

700 PARAISO STREET

ouse/Block/Lot No. Street
N/A SAN RAFAEL
Subdivision/Village Barangay
GUIMBA NUEVA ECIJA
City/Municipality Province

N/A PUROK I
ouse/Block/Lot No. Street
N/A CAVITE
Subdivision/Village Barangay
NUEVA ECIJA
City/Municipality Province

937

cruz@gmail.com

HILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

JUAN R. DELA CRUZ, JR. 06/24/2018

 (Continue on separate sheet if necessary)

HIGHEST LEVEL/
PERIOD OF ATTENDANCE YEAR SCHOLARSHIP/
UNITS
GRADUATED ACADEMIC HONORS
EARNED RECEIVED
(if not graduated)
To

2007 2007 SALUTATORIAN

2011 2011 N/A

DEAN'S
2015 2015
LISTER

2019 2021 N/A

2019 2019 N/A

PRESENT 30 UNITS N/A ALUMNI SCHOLARSHIP

DATE JUNE 1, 2022

CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable)
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

LICENSURE EXAMINATION FOR TEACHERS 89.23 12/07/2019 BAGUIO CITY

NUEVA ECIJA HIGH SCHOOL, CABANATUAN

CIVIL SERVICE PROFESSIONAL ELIGIBILITY 95.18 05/03/2015
CITY, NUEVA ECIJA

(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.
28. INCLUSIVE DATES
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY
(Write in full/Do not (Write in SALARY
abbreviate) full/Do not abbreviate)
From To

SAN RAFAEL SENIOR HIGHSCHOOL / DEPARTMENT OF

08/06/2022 PRESENT TEACHER II EDUCATION SCHOOLS DIVISION OF NUEVA ECIJA 27,608.00

SAN RAFAEL SENIOR HIGHSCHOOL / DEPARTMENT OF

01/01/2022 08/05/2022 TEACHER II EDUCATION SCHOOLS DIVISION OF NUEVA ECIJA 27,608.00

SAN RAFAEL SENIOR HIGHSCHOOL / DEPARTMENT OF

01/01/2021 12/31/2021 TEACHER II EDUCATION SCHOOLS DIVISION OF NUEVA ECIJA 26,052.00

SAN RAFAEL SENIOR HIGHSCHOOL / DEPARTMENT OF

01/01/2020 12/31/2020 TEACHER II EDUCATION SCHOOLS DIVISION OF NUEVA ECIJA 24,495.00

SAN RAFAEL SENIOR HIGHSCHOOL / DEPARTMENT OF

08/06/2019 12/31/2019 TEACHER II EDUCATION SCHOOLS DIVISION OF NUEVA ECIJA 22,938.00

PERSONNEL SECTION / DEPARTMENT OF EDUCATION

08/13/2018 08/05/2019 ADMINISTRATIVE ASSISTANT III SCHOOLS DIVISION OF NUEVA ECIJA 17,473.00

SAN ANDRES HIGH SCHOOL / DEPARTMENT OF EDUCATION

08/29/2017 08/12/2018 ADMINISTRATIVE ASSISTANT III SCHOOLS DIVISION OF NUEVA ECIJA 16,986.00

OFFICE OF THE DEPUTY EXECUTIVE DIRECTOR FOR

01/01/2017 08/28/2017 CLERK III ADMINISTRATIVE SERVICES AND FINANCE / PHILIPPINE RICE 15,505.00
RESEARCH INSTITUTE
HUMAN RESOURCE MANAGEMENT OFFICE /
05/02/2016 12/30/2016 CLERK III ADMINISTRATIVE SUPPORT DIVISION / PHILIPPINE RICE 15,505.00
RESEARCH INSTITUTE
COMPREHENSIVE LAND USE PLAN MUNICIPAL PLANNING AND DEVELOPMENT OFFICE / LOCAL
06/22/2015 04/30/2016 GOVERNMENT UNIT OF GUIMBA 4,000.00
(CLUP) STAFF
HUMAN RESOURCE DEPARTMENT / GREEN APPLE FOOD
11/13/2014 01/29/2015 ON-THE-JOB TRAINEE FACTORY INC. N/A
AGRONOMY, SOILS AND PLANT PHYSIOLOGY DIVISION /
04/26/2013 06/01/2013 EMERGENCY LABORER PHILIPPINE RICE RESEARCH INSTITUTE MINIMUM
 (Continue on separate sheet if necessary)

SIGNATURE DATE JUNE 1, 2

CS FOR
 LICENSE (if applicable)
ATION / CONFERMENT
NUMBER Date of
Validity

UIO CITY 1153169 09/10/2024

SCHOOL, CABANATUAN
N/A N/A
UEVA ECIJA

Experience sheet.
GOV'T
SALARY/ JOB/ PAY SERVICE
GRADE (if
STATUS OF
applicable)& STEP
(Format "00-0")/ APPOINTMENT
INCREMENT
(Y/ N)

12-2 PERMANENT YES

12-1 PERMANENT YES

12-1 PERMANENT YES

12-1 PERMANENT YES

12-1 PERMANENT YES

9-1 PERMANENT YES

9-1 PERMANENT YES

SERVICE
N/A CONTRACTOR
NO
`
SERVICE
N/A CONTRACTOR
NO

N/A JOB ORDER YES

N/A N/A NO

N/A JOB ORDER NO

JUNE 1, 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

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
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy)
From To
SAFE PLACES: POLICY RECOMMENDATIONS ON PROTECTING THE YOUTH IN EMERGENCIES AND
DISASTER 9/12/2021 9/12/2021 8

WEBINAR SERIES ON RESILIENT CURRICULUM AND INSTRUCTION 2/7/2021 7/7/2021 16

STRATEGIES FOR WRITING YOUR LITERATURE REVIEW: SCREENING PAPERS AND SYNTHESIZING
RESULTS 02/25/2021 02/25/2021 8

ADJUSTING TO “NEW NORMAL”: THE COLLABORATION OF PSYCHOLOGY AND TECHNOLOGY 02/24/2021 02/24/2021 8

NRCP REGIONAL BASIC RESEARCH CARAVAN “NURTURING REGIONAL R&D NICHES” 02/03/2021 02/03/2021 8
7TH INTERNATIONAL CONFERENCE ON INTEGRATIVE DISASTER RISK REDUCTION AND
MANAGEMENT (ICIDRRM) 12/10/2020 12/10/2020 8

IN-HOUSE REVIEW OF GENDER AND DEVELOPMENT OFFICE 11/19/2020 11/19/2020 8

MENTORING THE MENTORS IN DIGITAL TEACHING & LEARNING 05/18/2020 11/6/2020 152

REFRAMING EDUCATION FOR THE NEW NORMAL 06/17/2019 06/17/2019 8

TWO-DAY TRAINING ON THE INTEGRATION OF INDIGENOUS PEOPLES' EDUCATION/STUDIES INTO
THE RELEVANT HIGHER EDUCATION INSTITUTION CURRICULA 08/25/2019 08/26/2019 16
OPEN-FORUM FOR APPOINTMENT PREPARATION AND OTHER PERSONNEL
11/19/2018 11/21/2018 24
ACTIONS
VALIDATION OF THE SENIOR HIGH SCHOOL HIRING POLICY 08/28/2018 09/01/2018 40
TEACHERS COLLABORATE IN THE 21st CENTURY SCHOOLS TOWARDS
01/25/2018 01/27/2018 24
CONTINUOUS PROFESSIONAL DEVELOPMENT
2019 SYMPOSIUM FOR RESEARCH METHODS & INTERNATIONAL PUBLICATION 01/20/2018 01/20/2018 8

PHILGEPS POSTING AND TAX VALIDATION 11/07/2017 11/07/2017 8

IN-SERVICE TRAINING FOR SECONDARY SCHOOL TEACHERS OF GUIMBA,
10/23/2017 10/25/2017 24
CUYAPO AND NAMPICUAN
DIVISION ROLL-OUT OF THE FINANCIAL MANAGEMENT OPERATIONS MANUAL
10/15/2017 10/17/2017 24
(FMOM) FOR NON-IMPLEMENTING UNITS
TRAINING ON LEAVE ADMINISTRATION COURSE FOR THE EFFECTIVENESS (LACE),
ETHICAL STANDARDS OF A GOVERNMENT EMPLOYEE AND FINANCIAL MATTERS
08/22/2017 08/22/2017 8

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32.
(Write in full)

COMPUTER LITERATE (MICROSOFT WORD,

N/A
POWERPOINT& EXCEL)
VIDEO EDITING

(Continue on separate sheet if necessary)

SIGNATURE DATE
GANIZATION/S

POSITION / NATURE OF WORK

Managerial positions)

Type of LD
( Managerial/ CONDUCTED/ SPONSORED BY
Supervisory/ (Write in full)
Technical/etc)

TECHNICAL NATIONAL RESEARCH COUNCIL OF THE PHILIPPINES

TECHNICAL COMMISSION ON HIGHER EDUCATION

TECHNICAL EDITAGE SCHOLARCY

UNIVERSITAS MURIA KUDUS

TECHNICAL NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY

DEPARTMENT OF SCIENCE AND TECHNOLOGY / NATIONAL

TECHNICAL RESEARCH COUNCIL OF THE PHILIPPINES

TECHNICAL EASTERN SAMAR STATE UNIVERSITY

GENDER AND DEVELOPMENT CENTER / NUEVA ECIJA

TECHNICAL UNIVERSITY OF SCIENCE AND TECHNOLOGY

UNIVERSITY TRAINING DEPARTMENT & LEARNING AND

TECHNICAL DEVELOPMENT UNIT

GRADUATE SCHOOL / NUEVA ECIJA UNIVERSITY OF SCIENCE

TECHNICAL AND TECHNOLOGY

TECHNICAL NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY

TECHNICAL DEPARTMENT OF EDUCATION / CIVIL SERVICE COMMISSION

DEPARTMENT OF EDUCATION - BUREAU OF HUMAN RESOURCE

TECHNICAL AND ORGANIZATIONAL DEVELOPMENT

SAN ANDRES HIGH SCHOOL - DEPARTMENT OF

TECHNICAL EDUCATION
GRADUATE SCHOOL STUDENT COUNCIL OF NUEVA ECIJA
TECHNICAL UNIVERSITY OF SCIENCE AND TECHNOLOGY

TECHNICAL DEPARTMENT OF EDUCATION

 TECHNICAL DEPARTMENT OF EDUCATION

TECHNICAL DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION & CIVIL
TECHNICAL
SERVICE COMMISSION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
33. (Write in
full)

N/A

DATE JUNE 1, 2022

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,
YES NO
a. within the third degree?
✘

YES
b. within the fourth degree (for Local Government Unit - Career Employees)? ✘ NO
If YES, give details:
________________________________

35. a. Have you ever been found guilty of any administrative offense?
YES ✘ NO
If YES, give details:
________________________________
________________________________
YES ✘ NO
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
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? ________________________________
END OF CONTRACT; RESIGNAT
________________________________
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
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
If YES, please specify:
b. Are you a person with disability? YES
If YES, please specify ID No:
c. Are you a solo parent? YES
If YES, please specify ID No:

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

NAME ADDRESS TEL. NO.

JUAN B. DULDULAO MALIGAYA, SCIENCE CITY OF MUÑOZ, NUEVA ECIJA 0999-799-2784

CASIANO R. DIRECTO TALUGTUG, NUEVA ECIJA 0996-389-8034

 MABINI EXTENSION, CABANATUAN CITY,
ROSE C. TALIANO NUEVA ECIJA
0996-334-7777
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
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: PRC ID
ID/License/Passport No.: 1153169 Signature (Sign inside the box)
JUNE 1, 2022
Date/Place of Issuance: 12/7/2019 / BAGUIO CITY
Date Accomplished

SUBSCRIBED AND SWORN to before me this JUNE 2, 2022 , affiant exhibiting

  his/her validly issued government ID as indicated above.
 
ATTY. FABRO S. CASTRO
NOTARY PUBLIC
UNTIL JUNE 30, 2022
PTR NO/ 7649833 1/1/2022
IBP No. 136405, 02/14/2021
NOTARIAL COMMISSION
Person Administering Oath07/20
GUIMBA, NUEVA ECIJA
 
CS FORM 212 (Rev
 ✘

NO

✘ NO
give details:
________________________

✘ NO
give details:
________________________
________________________
✘ NO

give details:
________________________
________________________

✘ NO
give details:
________________________
________________________
NO
give details:
________________________
D OF CONTRACT; RESIGNATION
________________________

✘ NO

✘ NO

✘ NO
give details (country):

✘ NO

✘ NO
ease specify ID No:
✘ NO
ease specify ID 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
or photocopied picture
is not acceptable
 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
or photocopied picture
is not acceptable

PHOTO

Right Thumbmark

d government ID as indicated above.

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