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 PESANO

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

MIDDLE NAME DELOS SANTOS

3. DATE OF BIRTH
(mm/dd/yyyy) 3/2/1993 16. CITIZENSHIP
Filipino Dual Citizenship
by birth ✘ by naturalization
4. PLACE OF BIRTH SAMPALOC, 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 BLOCK 13 LOT 1 PHASE 1 SMTI
Widowed Separated House/Block/Lot No. Street
BAGONG NAYON II SAN ISIDRO
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 1.62 ANTIPOLO RIZAL
City/Municipality Province
8. WEIGHT (kg) 69.8 ZIP CODE 1870

9. BLOOD TYPE A
18. PERMANENT ADDRESS 744 DOMINGO SANTIAGO
House/Block/Lot No. Street
10. GSIS ID NO. N/A 580
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1211-1333-7434 MANILA NCR

City/Municipality Province

12. PHILHEALTH NO. 030255683620 ZIP CODE 1008

13. SSS NO. 34-4120138-4 19. TELEPHONE NO. N/A

14. TIN NO. 449-347-313-0000 20. MOBILE NO. 09453327063

15. AGENCY EMPLOYEE NO.
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME
FIRST NAME
6457560 21. E-MAIL ADDRESS (if any) moonrose.pesano@deped.gov.ph
N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
N/A N/A

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME PESANO

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

MIDDLE NAME PATEÑO

25. MOTHER'S MAIDEN NAME RAFOL

SURNAME PESANO

FIRST NAME ESPERANZA

MIDDLE NAME DELOS SANTOS (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
(Write in full) HONORS
full) (if not graduated) RECEIVED
From To

ELEMENTARY STA. PEREGRINA ELEMENTARY SCHOOL ELEMENTARY 2001 2007 GRADUATED 2007 N/A

SECONDARY /
VOCATIONAL ANTIPOLO NATIONAL HIGH SCHOOL HIGH SCHOOL 2007 2011 GRADUATED 2011 N/A

N/A
TRADE
BACHELOR IN ELEMENTARY
COURSE MAGNA CUM
COLLEGE NATIONAL UNIVERSITY EDUCATION- MAJOR IN GENERAL 2016 2019 GRADUATED 2019
LAUDE
EDUCATION

GRADUATE STUDIES N/A

(Continue on separate sheet if necessary)
SIGNATURE DATE 03/13/2023
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL DATE OF LICENSE (if applicable)
RATING
LAWS/ CES/ CSEE BARANGAY EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity

LICENSURE EXAMINATION FOR TEACHERS 84.20 09/29/2019 GERONIMO SANTIAGO ELEMENTARY SCHOOL 1829302 02/03/2023

(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. SALARY/ JOB/ PAY SERVICE
INCLUSIVE DATES (mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
STATUS OF
(Write in MONTHLY SALARY applicable)& STEP
APPOINTMENT
(Format "00-0")/
full/Do not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To
(Y/ N)
DEPARTMENT OF EDUCATION - DIVISION OF ANTIPOLO
03/14/2022 PRESENT TEACHER I CITY / BAGONG NAYON II ELEMENTARY SCHOOL Php 27,000 11-1 PERMANENT Y

(Continue on separate sheet if necessary)

SIGNATURE DATE 03/13/2023
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

SCHOOL-BASED IN SERVICE TRAINING (INSET) 02/08/2023 02/10/2023 24 TECHNICAL BAGONG NAYON II ELEMENTARY SCHOOL
SCHOOL-BASED TRAINING WORKSHOP ON BASIC COMPUTER SERVICING CUM
11/29/2022 01/02/2022 24 TECHNICAL BAGONG NAYON II ELEMENTARY SCHOOL
PHOTO EDITING
THE 2022 SCIENCE LEARNING ACTION CELL (LAC SESSION) IN STRATEGIES IN
11/16/2022 11/18/2022 24 TECHNICAL BAGONG NAYON II ELEMENTARY SCHOOL
TEACHING
SCHOOL LEARNING ACTION CELL (SLAC) SESSION ON STRATEGIES IN
12/12/2022 12/14/2022 24 TECHNICAL BAGONG NAYON II ELEMENTARY SCHOOL
TEACHING READING TO STRUGGLING LEARNERS IN MODERN ERA
Technical Education and Skills Development Authority - National Certificate III in Event CENTRAL RIZAL INSTITUTE OF TECHNOLOGY
Management Services
08/23/2021 09/08/2021 108 TECHNICAL
INC.
INTERNATIONAL TRAINING ON SCHOOL LEADERSHIP AND PEDAGOGICAL PHILIPPINE CONTINUING PROFESSIONAL
06/07/2021 06/12/2021 144 TECHNICAL
ENHANCEMENT FOR 21ST CENTURY EDUCATORS DEVELOPMENT TRAINING CENTER

(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)

LISTENING MUSIC N/A N/A

WATCHING CRIME DOCUMENTARY

(Continue on separate sheet if necessary)

SIGNATURE DATE 03/13/2023

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 ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘

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:
DON BOSCO TECHNICAL INSTITUTE OF MAKATI -
c. Are you a solo parent? CHINO ROCES AVENUE MAKATI CITY
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
DONDON BUENSUCESO CHINO ROCES AVENUE MAKATI CITY 09778818008 3.5 cm. X 4.5 cm
(passport size)
1468 J. FAJARDO ST. BRGY. 430,
SUSAN D. GOPEZ 09289583311 With full and handwritten
SAMP.MANILA name tag and signature over
27 ACACIA ST. NEW MANILA printed name
AUDREY ELEONOR TONG 09175768486
QUEZON CITY 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 filing of PHOTO
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 Professional Teacher ID

ID/License/Passport No.: 1829302

Signature (Sign inside the box)
03/13/2023
Date/Place of Issuance: 2020/Manila
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