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 MEPAÑA
NAME EXTENSION (JR., SR) N/A
FIRST NAME JAY PEARL
MIDDLE NAME BATAC
3. DATE OF BIRTH
(mm/dd/yyyy) 1/1/1996 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
✘ by birth
4. PLACE OF BIRTH PASIG CITY, METRO MANILA If holder of dual citizenship, Pls. indicate country: naturalization
please indicate the details.
5. SEX Female
Male ✘

6 CIVIL STATUS ✘ Single Married

17. RESIDENTIAL ADDRESS PUROK 2 N/A
House/Block/Lot No. Street
Widowed Separate
Other/s: N/A UNION
d Subdivision/Village Barangay
7. HEIGHT (m) 2 TAGANA-AN SURIGAO DEL NORTE
City/Municipality Province
8. WEIGHT (kg) 55 ZIP CODE 8403
9. BLOOD TYPE O+
18. PERMANENT ADDRESS PUROK 2 N/A
House/Block/Lot No. Street
10. GSIS ID NO. N/A N/A UNION
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121187315881 TAGANA-AN SURIGAO DEL NORTE

City/Municipality Province

12. PHILHEALTH NO. 18-250857966-8 ZIP CODE 8403

13. SSS NO. 34-6420269-0 19. TELEPHONE NO. 0868162750
14. TIN NO. 335-326-797-00000 20. MOBILE NO. 09500693668
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) jpearlmepana1996@gmail.com
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)

NAME EXTENSION (JR., SR)

FIRST NAME N/A N/A TIA LEONIE MEPAÑA DORIMON 01/22/2020
MIDDLE NAME N/A
OCCUPATION N/A
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME MEPAÑA
NAME EXTENSION (JR., SR)
FIRST NAME JERRY N/A

MIDDLE NAME MACARENI

25. MOTHER'S MAIDEN NAME

SURNAME BATAC
FIRST NAME PERLITA
MIDDLE NAME BULADACO (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
From To

MAYBUNGA ELEMENTARY SCHOOL 2002 2007 GRADE 5 8TH HONOR

ELEMENTARY ELEMENTARY EDUCATION
TAGANA-AN CENTRAL ELEMENTARY
2007 2008 GRADUATED 2008 SALUTATORIAN
SCHOOL
SECONDARY /
VOCATIONAL TAGANA-AN NATIONAL HIGH SCHOOL SECONDARY EDUCATION 2008 2012 GRADUATED 2012 SALUTATORIAN

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

TRADE
SURIGAO STATE COLLEGE OF BACHELOR OF SCIENCE IN
COURSE
COLLEGE 2012 2016 GRADUATED 2016 N/A
TECHNOLOGY ELEMENTARY EDUCATION

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

(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 88.00% 10/02/2022 BACOLOD CITY 2047583 01/01/2026

(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
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)

04/10/2022 PRESENT TEACHER 1 DEPED DIVISION OF SURIGAO DEL NORTE ₱25,439.00 11-1 PERMANENT Y

02/07/2018 02/28/2022 IMPLEMENTING TEACHER (MINING PAID) HINATUAN INTEGRATED SCHOOL ₱13,000.00 N/A CONTRACTUAL Y
QUALFON CEBU PHILIPPINES
10/29/2015 12/26/2016 CUSTOMER SERVICE REPRESENTATIVE ₱15,000.00 N/A REGULAR N
INCORPORATED

(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

LOWER BUSAY OUTREACH 05/13/2016 05/13/2016 8 VOLUNTEER

RANDOM ACTS OF KINDNESS; COLON ST. BREAKFAST DAY FOR THE HOMELESS 06/17/2016 06/17/2016 8 VOLUNTEER

SCHOOL SUPPLIES GIVING IN DAS LUTOPAN 07/15/2016 07/15/2016 8 VOLUNTEER

SCHOOL SUPPLIES GIVING IN PITALO SAN FERNANDO 07/26/2016 07/26/2016 8 VOLUNTEER

SLIPPERS DRIVE IN SAMBAG 1, CEBU CITY 10/08/2016 10/08/2016 8 VOLUNTEER

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
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

OFFICE OF THE UNDERSECRETARY FOR

ADMINISTRATION (OUA) through the INFORMATION AND
VIRTUAL IN-SERVICE TRAINING FOR TEACHERS 08/30/2021 09/03/2021 40 TECHNICAL COMMUNICATIONS TECHNOLOGY SERVICES-EDUCATION
TECHNOLOGY UNIT (ICTS-Ed-Tech)

DEPARTMENT OF EDUCATION,TAGANA-AN
ON SITE CLUSTER SCHOOLS MONITORING EVALUATION (INSET) 03/17/2021 03/19/2021 24 TECHNICAL
DISTRICT/DIVISION OF SURIGAO DEL NORTE
DEPARTMENT OF EDUCATION,TAGANA-AN
5 DAY SCHOOL BASED LAC SESSION 09/21/2020 09/25/2020 40 TECHNICAL
DISTRICT/DIVISION OF SURIGAO DEL NORTE
SOUTHEAST ASIAN INSTITUTE OF EDUCATIONAL
INTERNATIONAL TRAINING SERIES ON NEW TRENDS IN EDUCATION 09/20/2019 09/22/2020 24 TECHNICAL
TRAINING, INCORPORATED
DEPARTMENT OF EDUCATION,TAGANA-AN
2 DAY DISTRICT BASED SEMINAR WORKSHOP ON PPST-RPMS 04/29/2019 04/30/2019 16 TECHNICAL
DISTRICT/DIVISION OF SURIGAO DEL NORTE
DIVISION RETOOLING OF SCHOOL HEADS IN CRAFTING ENHANCED SCHOOL DEPARTMENT OF EDUCATION/DIVISION OF
12/09/2018 12/11/2018 24 TECHNICAL
IMPROVEMENT PLAN 2019-2021 SURIGAO DEL NORTE

3 DAY DISTRICT BASED SEMINAR WORKSHOP ON PHILIPPINE PROFESSIONAL DEPARTMENT OF EDUCATION,TAGANA-AN

07/19/2018 07/21/2018 24 TECHNICAL
STANDARDS FOR TEACHERS RESULTS-BASED PERFORMANCE MANAGEMENT SYSTEM DISTRICT/DIVISION OF SURIGAO DEL NORTE

3 DAY DISTRICT IN SERVICE TRAINING IN TITLED;BLESS DEP-ED TAGANA-AN;BUILDING DEPARTMENT OF EDUCATION,TAGANA-AN

02/24/2017 02/26/2017 24 TECHNICAL
LEARNING TEAMS FOR SUCCESSFUL SCHOOLS DISTRICT/DIVISION OF SURIGAO DEL NORTE
PROVINCIAL TRAINING CENTER/TESDA/LGU-
COMPUTER SYSTEM SERVICING NC-II 04/15/2017 05/15/2017 320 TECHNICAL
SURIGAO DEL NORTE
ARMS COMPUTER SERVICES, MAINIT, SURIGAO
10 DAY SKILLS DEVELOPMENT TRAINING ON COMPUTER BASIC COURSES 12/01/2016 12/10/2016 80 TECHNICAL
DEL NORTE

(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)
VOLUNTEER OF QUALFON PHILIPPINES
COMPUTER LITERATE (MICROSOFT OFFICES) N/A
INCORPORATED
TIME MANAGEMENT

ABILITY TO WORK UNDER PRESSURE

TASK PRIORITIZATION

INTERNET SURFING

(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 ✘

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
by any court or tribunal? YES ✘ NO
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
________________________________
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
DEPARTMENT OF EDUCATION, TAGANA-AN the last 6 months
ADELA S. CABUGA PhD. DISTRICT
09303939724 4.5 cm. X 3.5 cm
(passport size)
DEPARTMENT OF EDUCATION, TAGANA-AN
RUEL B. DIAZ DISTRICT
09302968463
Computer generated
or photocopied picture
DEPARTMENT OF EDUCATION, TAGANA-AN
DOMINGO A. CUARENTA JR. DISTRICT
09483226511 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.)

PLEASE INDICATE ID Number and Date of
Issuance
Government Issued ID: PRC
ID/License/Passport No.: 1467881 Signature (Sign inside the box)

Date/Place of Issuance: 06/24/2016 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