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 SANSAN
NAME EXTENSION (JR., SR)
FIRST NAME DIANNE n/a

MIDDLE NAME PEREZ

3. DATE OF BIRTH
12/10/1986 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH SAPANG PALAY BULACAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female
17. RESIDENTIAL ADDRESS BLOCK 69 LOT 13
6 CIVIL STATUS Single ✘ Married
House/Block/Lot No. Street
Widowed Separated
San rafael IV
Other/s:
Subdivision/Village Barangay
CITY SAN JOSE DEL MONTE BULACAN BULACAN
7. HEIGHT (m) 1.5
City/Municipality Province
8. WEIGHT (kg) 60 ZIP CODE 3023
18. PERMANENT ADDRESS BLOCK 69 LOT 13
9. BLOOD TYPE A+
House/Block/Lot No. Street
San rafael IV
10. GSIS ID NO. 2004651250
Subdivision/Village Barangay
CITY SAN JOSE DEL MONTE BULACAN BULACAN
11. PAG-IBIG ID NO. 1211-5784-3267
City/Municipality Province

12. PHILHEALTH NO. 21-050009177-5 ZIP CODE 3023

13. SSS NO. 00-34-061-25-65-4 19. TELEPHONE NO. N/A

14. TIN NO. 263-558-057-000 20. MOBILE NO. 09154964495

15. AGENCY EMPLOYEE NO.
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME
FIRST NAME
4670250 21. E-MAIL ADDRESS (if any) dianne.sansan@deped.gov.ph
SANSAN 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) SANSAN, MARY DAVEAN PEREZ
ANDREW N/A 01/24/2008

MIDDLE NAME DINERO SANSAN, DAN ANDREX PEREZ 08/16/2013

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME PEREZ

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

MIDDLE NAME RECAFORT

25. MOTHER'S MAIDEN NAME

SURNAME SARMIENTO

FIRST NAME FELIZA

MIDDLE NAME ALEJANDRE (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

ELEMENTARY BAGONG BUHAY H ELEMENTARY SCHOOL PRIMARY EDUCATION 1993 1999 GRADUATE 1999 N/A

SECONDARY
VOCATIONAL / SAPANG PALAY NATIONAL HIGH SCHOOL SECONDARY 1999 2003 GRADUATE 2003 N/A

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

TRADE
COURSE BACHELOR OF SECONADARY EDUCATION
COLLEGE Colegio de San Gabriel Arcangel
MAJOR IN GUIDANCE AND COUNSELING
2003 2007 GRADUATE 2007 N/A

GRADUATE STUDIES POLYTECHNIC UNIVERSITY OF THE PHILIPPINES MASTER IN EDUCATIONAL MANAGEMENT 2016 2018 36 UNITS N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE 12/05/2023

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 Date of
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity

Licensure Examination for Professional Teachers 77.8 03/10/2013 Manila 1214894 12/10/2026

(Continue on separate sheet if necessary)

GOV'T
V. WORK EXPERIENCE
SERVICE
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experience sheet.
28. INCLUSIVE DATES SALARY/ JOB/ PAY
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY
(Write in SALARY
applicable)& STEP STATUS OF APPOINTMENT
(Format "00-0")/
(Write in full/Do not abbreviate) full/Do not abbreviate) INCREMENT
From To

DEPARTMENT OF EDUCATION
DIVISION OF CITY SCHOOLS
(Y/ N)
01/01/2023 PRESENT Teacher 1 P27,573 11-3 REGULAR/ PERMANENT YES
CITY OF SAN JOSE DEL MONTE

SAN JOSE DEL MONTE NATIONAL HIGH SCHOOL

DEPARTMENT OF EDUCATION
DIVISION OF CITY SCHOOLS
01/01/2021 12/31/2021 Teacher 1 P24,161 11-2 REGULAR/ PERMANENT YES
CITY OF SAN JOSE DEL MONTE

SAN JOSE DEL MONTE NATIONAL HIGH SCHOOL

DEPARTMENT OF EDUCATION
DIVISION OF CITY SCHOOLS
01/01/2021 12/31/2021 Teacher 1 P23,877 11-2 REGULAR/ PERMANENT YES
CITY OF SAN JOSE DEL MONTE

SAN JOSE DEL MONTE NATIONAL HIGH SCHOOL

DEPARTMENT OF EDUCATION
DIVISION OF CITY SCHOOLS
01/01/2020 12/31/2020 Teacher 1 P22,316 11-2 REGULAR/ PERMANENT YES
CITY OF SAN JOSE DEL MONTE

SAN JOSE DEL MONTE NATIONAL HIGH SCHOOL

DEPARTMENT OF EDUCATION
DIVISION OF CITY SCHOOLS
01/01/2019 12/31/2019 Teacher 1 P21,038 11-2 REGULAR/ PERMANENT YES
CITY OF SAN JOSE DEL MONTE

SAN JOSE DEL MONTE NATIONAL HIGH SCHOOL

DEPARTMENT OF EDUCATION
DIVISION OF CITY SCHOOLS
01/01/2018 12/31/2018 Teacher 1 P20,120 11-1 REGULAR/ PERMANENT YES
CITY OF SAN JOSE DEL MONTE

SAN JOSE DEL MONTE NATIONAL HIGH SCHOOL

DEPARTMENT OF EDUCATION
DIVISION OF CITY SCHOOLS
01/01/2017 12/31/2017 Teacher 1 P19,620 11-1 REGULAR/ PERMANENT YES
CITY OF SAN JOSE DEL MONTE

SAN JOSE DEL MONTE NATIONAL HIGH SCHOOL

DEPARTMENT OF EDUCATION
DIVISION OF CITY SCHOOLS
06/22/2016 12/31/2016 Teacher 1 P18,549 11-1 Permanent YES
CITY OF SAN JOSE DEL MONTE
DEPARTMENT OF EDUCATION
DIVISION OF CITY
SAN JOSE DEL SCHOOLS
MONTE NATIONAL HIGH SCHOOL
09/03/2014 03/31/2015 SUBSTITUTE TEACHER DEPARTMENT OF EDUCATION P18,549 11 SUBSTITUTE YES
CITY OF SAN
DIVISION JOSESCHOOLS
OF CITY DEL MONTE

07/22/2013 10/16/2013 SUBSTITUTE TEACHER SAN JOSE DEL MONTE NATIONAL HIGH SCHOOL P13,565 11 SUBSTITUTE YES
CITY OF SAN JOSE DEL MONTE

07/11/2008 06/30/2013 PRIVATE TEACHER COLLEGE

SAN OFMONTE
JOSE DEL SAINTNATIONAL
ADELA HIGH
INC SCHOOL P8,500 N/A CONTRACTUAL NO

06/01/2007 06/30/2008 PRIVATE TEACHER COLLEGE OF SAINT THERESE P5,000 N/A CONTRACTUAL NO

(Continue on separate sheet if necessary)

SIGNATURE DATE 12/05/2023
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 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
ATTENDANCE Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(Write in full) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To

SCHOOLS DIVISION TRAINING WORKSHOP ON THE DEVELOPMENT OF DEPARTMENT OF EDUCATION

11/25/2022 11/27/2022 24 TECHNICAL DIVISION OF CITY SCHOOLS
ASSESSMENT TOOLS FOR LEARNERS CITY OF SAN JOSE DEL MONTE
DEPARTMENT OF EDUCATION
IN SEVICE TRAINING FOR TEACHERS 08/16/2022 08/20/2022 40 TECHNICAL SAN JOSE DEL MONTE NATIONAL HIGH
SCHOOL
DALUYAN 2.0: FREE REGIONAL TRAINING FOR GOOD MANNERS AND RIGHT DEPARTMENT OF EDUCATION
CONDUCT (GMRC) AND VALUES EDUCATION TEACHERS WITH 05/23/2022 05/27/2022 40 TECHNICAL DEPED REGION OFFICE
DEMONSTRATION TEACHING

DEPARTMENT OF EDUCATION
IN SEVICE TRAINING FOR TEACHERS 02/14/2022 02/18/2022 41 TECHNICAL SAN JOSE DEL MONTE NATIONAL HIGH
SCHOOL

BSP REGION III

CLR-DIGITAL REGIONAL JAMBOREE 10/15/2021 10/30/2021 120 TECHNICAL BULACAN COUNCIL

DEPARTMENT OF EDUCATION
VIRTUAL IN SERVICE TRAINING FOR TEACHERS 8/30/2021 09/3/2021 40 TECHNICAL DEPED CENTRAL OFFICE

BSP BULACAN COUNCIL

DIVISION OF CITY SCHOOLS
BSP- BULACAN COUNCIL MESSENGER OF PEACE WEBINAR 8/13/2021 8/13/2021 8 TECHNICAL CITY OF SAN JOSE DEL MONTE

DEPARTMENT OF EDUCATION
BASIC TRAINING IN NIHONGGO 7/19,2021 7/23/2021 40 TECHNICAL DIVISION OF CITY SCHOOLS
CITY OF SAN JOSE DEL MONTE

SCIENTIFIC RESEARCH WRITING AND REVIEWING 7/25/2021 7/25/2021 8 TECHNICAL IBSTITUTE OF GLOBAL PROFESSIONAL

BSP BULACAN COUNCIL

BSP- BULACAN COUNCIL TIDE TURNER PLASTIC CHALLENGE WEBINAR 7/13/2021 7/14/2021 16 TECHNICAL DIVISION OF CITY SCHOOLS
CITY OF SAN JOSE DEL MONTE

BSP BULACAN COUNCIL

DIVISION OF CITY SCHOOLS
BSP- BULACAN COUNCIL WEBINAR ON ROAD SAFETY AWARENESS 5/10/2021 5/10/2021 8 TECHNICAL
CITY OF SAN JOSE DEL MONTE

BSP BULACAN COUNCIL

BSP IN THE CONTEXT OF COVID-19 PANDEMIC "KEEPING THE SCOUTING MOVEMENT 9/24/2020 DIVISION OF CITY SCHOOLS
9/29/2020 24 TECHNICAL CITY OF SAN JOSE DEL MONTE
ALIVE 9/28/2020

DEPARTMENT OF EDUCATION
WEBINAR FOR EDUKASYON SA PAGPAPAKATAO TEACHERS: MEETING THE DEMANDS DIVISION OF CITY SCHOOLS
7/29/2020 7/31/2020 24 TECHNICAL CITY OF SAN JOSE DEL MONTE
OF NEW NORMAL

DEPARTMENT OF EDUCATION
DIVISION OF CITY SCHOOLS
DIVISION TRAINING FOR UNTRAINED ESP TEACHER 04/10/2019 04/11/2019 36 TECHNICAL CITY OF SAN JOSE DEL MONTE
SAN JOSE DEL MONTE NATIONAL HIGH SCHOOL

DEPARTMENT OF EDUCATION
DIVISION TRAINING ON CONTENT AND PEDAGOGY FOR JUNIOR HIGH SCHOOL DIVISION OF CITY SCHOOLS
10/24/2018 10/26/2018 24 TECHNICAL
TAEACHER CITY OF SAN JOSE DEL MONTE
SAN JOSE DEL MONTE NATIONAL HIGH SCHOOL
DEPARTMENT OF EDUCATION
DIVISION OF CITY SCHOOLS
BASIC TRAINING COURSE FOR UNIT LEADER 8/3/2018 8/5/2018 24 TECHNICAL CITY OF SAN JOSE DEL MONTE
CORNELIA M. DE JESUS SCHOOL, STA MARIA,
WEST DISTRICT
(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)
SAN JOSE DEL MONTE NATIONAL HIGH
COMPUTER LITERATE BEST CLUB ADVISER 2017
SCHOOL COOPERATIVE
BEST CLUB ADVISER 2016 SAN JOSE DEL MONTE COOPERATIVE

FACULTY EMPLOYEES ASSOCIATION

 BOYSCOUT OF THE PHILIPPINES
(Continue on separate sheet if necessary)

SIGNATURE DATE 12/05/2023

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 ✘ 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? FINISHED 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
MUZON, CITY OF SAN JOSE DEL MONTE the last 6 months
MARIA C. LAUDEN BULACAN
9453906986 3.5 cm. X 4.5 cm
(passport size)
BLOCK 3, LOT 12, CITY OF SAN JOSE
RACHALLE ANN F. MANALOTO DEL MONTE BULACAN
9751553416 With full and handwritten
name tag and signature over
printed name
TRICIA XYLYNE L. CALDELERO NORTH FAIRWAY HOMES 9330295384
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: PHILIPPINE REGULATION COMMISSION

ID/License/Passport No.: 1214894

Signature (Sign inside the box)
12/05/2023
Date/Place of Issuance: 05/21/2013/MANILA
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.

MA. JIMA T. CADIZ

Person Administering Oath

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