CS Form No.

212
Revised 2017
PERSONAL DATA SHEET
WARNING: Any misinterpretation made in the Personal Data Sheet and the Work Experience Sheet shall cause the filing of administrative/criminal case
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 NOT1.ABBREVIATE.
CS ID No (Do not fill up. For CSC

I. PERSONAL INFORMATION
2. SURNAME DIZON
NAME EXTENSION (JR., SR)
FIRST NAME NATHANEIL
MIDDLE NAME DELOS SANTOS
3. DATE OF BIRTH
(mm/dd/yyyy) 11/22/1970 16. CITIZENSHIP FILIPINO

4. PLACE OF BIRTH BINALONAN,PANGASINAN If holder of dual citizenship, Pls. indicate country:

please indicate the details.
5. SEX MALE N/A
17. RESIDENTIAL ADDRESS 28 WILLIAM TAFT STREET
6 CIVIL STATUS MARRIED
House/Block/Lot No. Street
N/A POBLACION
Subdivision/Village Barangay
BINALONAN PANGASINAN
7. HEIGHT (m) 1.63 M. City/Municipality Province
8. WEIGHT (kg) 65 KGS. ZIP CODE 2436
18. PERMANENT ADDRESS ZONE7 RIVERSIDE
9. BLOOD TYPE O
House/Block/Lot No. Street
N/A CALEPAAN
10. GSIS ID NO. 02003478497
Subdivision/Village Barangay
11. PAG-IBIG ID NO. 1280/0063/2949/8 ASINGAN PANGASINAN
City/Municipality Province
12. PHILHEALTH NO. 05/050029929/8 ZIP CODE 2439

13. SSS NO. 02/11453051 19. TELEPHONE NO. N/A

14. TIN NO. 918/186/809 20. MOBILE NO. 09323817193

15. AGENCY EMPLOYEE NO. 471701 21. E-MAIL ADDRESS (if any) nathaneildizon70@gmail.com
II. FAMILY BACKGROUND
23. NAME of CHILDREN (Write full name and list
22. SPOUSE'S SURNAME DIZON all)
DATE OF BIRTH (mm/dd/y
NAME EXTENSION (JR., SR)
FIRST NAME GENILYN JOHN LAYNARD TABION DIZON 12/23/1998
MIDDLE NAME TABION JOHN LLOYD TABION DIZON 10/5/2004
OCCUPATION TEACHING JOHN LOUIS TABION DIZON 2/7/2008
EMPLOYER/BUSINESS NAME DEPARTMENT OF EDUCATION JOHN LAMBERT TABION DIZON 4/19/2011

BUSINESS ADDRESS
BACTAD EAST NATIONAL HIGH
SCHOOL,URDANETA CITY
TELEPHONE NO. N/A
24. FATHER'S SURNAME DIZON
NAME EXTENSION (JR., SR)
FIRST NAME RUFINO
MIDDLE NAME ABIOG
25. MOTHER'S MAIDEN NAME

SURNAME DELOS SANTOS

FIRST NAME ESTELITA
MIDDLE NAME GANADEN (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY NORTH CENTRAL SCHOOL PRIMARY EDUCATION 1977 1983 GRADUATED 1983
VOCATIONAL / BINALONAN NATIONAL HIGH
SECONDARY
SCHOOL
HIGH SCHOOL 1983 1988 GRADUATED 1988
PANGASINAN MERCHANT
MARINE ACADEMY /DAGUPAN DIESL MECHANIC 1988 1989 GRADUATED 1989
CITY
TRADE URDANETA COMMUNITY BACHELOR OF SCIENCE IN
COLLEGE
COURSE COOLEGE ELEMENTARY EDUCATION
1995 1998 GRADUATED 1998

GRADUATE STUDIES URDANETA CITY UNIVERSITY M A IN Educational Management 2013 2014 6 N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE 04/24/2017 CS FORM 212 (Revised 2017), Page 1 of

AL DATA SHEET
nd the Work Experience Sheet shall cause the filing of administrative/criminal case/s

A SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

FILIPINO

Pls. indicate country:

WILLIAM TAFT STREET

Street
POBLACION
Barangay
PANGASINAN
Province
2436
RIVERSIDE
Street
CALEPAAN
Barangay
PANGASINAN
Province

N/A

09323817193

nathaneildizon70@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

12/23/1998

10/5/2004

2/7/2008

4/19/2011

(Continue on separate sheet if necessary)

SCHOLARSHIP/
ACADEMIC HONORS
 SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED

2ND HONORS
ATHLETIC
AWRDEE
5TH HONORS
ATHLETIC
AWRDEE
N/A
e on separate sheet if necessary)

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

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

LICENSURE EXAMS FOR TEACHERS 75% 8/1/1998 BAGUIO CENTRAL ELEMENTARY SCHOOL

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE

SALARY/ JOB/
INCLUSIVE DATES (mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY PAY GRADE (if
MONTHLY applicable)&
(Write in SALARY STEP (Format
(Write in full/Do not abbreviate) full/Do not abbreviate) "00-0")/
From To INCREMENT
DEPARTMENT OF EDUCATION
1/1/2017 present
TEACHER I PANGASINAN II 256644 11-3
DEPARTMENT OF EDUCATION
6/1/2016 12/31/2016
TEACHER I PANGASINAN II 233952 11-3
DEPARTMENT OF EDUCATION
1/1/2016 5/31/2016
TEACHER I PANGASINAN II 233952 11-3
DEPARTMENT OF EDUCATION
6/1/2015 12/31/2015
TEACHER I PANGASINAN II 227064 11-3
DEPARTMENT OF EDUCATION
3/25/2015 5/31/2015
TEACHER I PANGASINAN II 227064 11-3
DEPARTMENT OF EDUCATION
6/1/2014 3/24/2015
TEACHER I PANGASINAN II 227064 11-3
DEPARTMENT OF EDUCATION
3/25/2014 5/31/2014
TEACHER I PANGASINAN II 227064 11-3
6/1/2013 3/24/2014 DEPARTMENT OF EDUCATION
TEACHER I PANGASINAN II 224820 11-2
DEPARTMENT OF EDUCATION
6/1/2012 5/31/2013
TEACHER I PANGASINAN II 224820 11-2
6/1/2011 5/31/2012 DEPARTMENT OF EDUCATION
TEACHER I PANGASINAN II 207816 11-1
DEPARTMENT OF EDUCATION
3/25/2011 5/31/2011
TEACHER I PANGASINAN II 190800 11-1
DEPARTMENT OF EDUCATION
6/24/2010 3/24/2011
TEACHER I PANGASINAN II 187788 11-1
7/1/2009 6/23/2010
DEPARTMENT OF EDUCATION
TEACHER I PANGASINAN II 170376 11-1
7/1/2008 6/30/2009 DEPARTMENT OF EDUCATION
TEACHER I PANGASINAN II 144312 11-1
DEPARTMENT OF EDUCATION
3/25/2008 6/30/2008
TEACHER I PANGASINAN II 131196 11-1
DEPARTMENT OF EDUCATION PANGASINAN II
12/3/2007 2/2/2008 CLASSROOM TEACHER 131196 11-1

2/19/2005 2/21/2007 HEAVY EQUIPMENT MECHANIC STEIDLE READY MIX COMPANY SAUDI ARABIA 1,600 SR N/A
LYCEUM NORTHWESTERN UNIVERSITY
5/17/2004 12/1/2004 TEACHER 5280.00 N/A
DAGUPAN CITY
 LYCEUM NORTHWESTERN UNIVERSITY
6/16/2003 4/16/2004 TEACHER 5280.00 N/A
DAGUPAN CITY
LYCEUM NORTHWESTERN UNIVERSITY
6/25/2002 3/30/2003 TEACHER 5280.00 N/A
DAGUPAN CITY
LYCEUM NORTHWESTERN UNIVERSITY
10/1/2001 11/30/2001 TEACHER 5280.00 N/A
DAGUPAN CITY
LYCEUM NORTHWESTERN UNIVERSITY
5/22/2000 3/31/2001 TEACHER 4652.00 N/A
DAGUPAN CITY

(Continue on separate sheet if necessary)

SIGNATURE DATE 04/24/2017 CS FORM 212 (Revis

 LICENSE (if applicable)

NUMBER Date of
Validity

471701 10/8/1998

nue on separate sheet if necessary)

GOV'T
SERVICE

STATUS OF APPOINTMENT

(Y/
N)
PERMANENT YES

PERMANENT YES

PERMANENT YES

PERMANENT YES

PERMANENT YES

PERMANENT YES

PERMANENT YES

PERMANENT YES

PERMANENT YES

PERMANENT YES

PERMANENT YES

PERMANENT YES

PERMANENT YES

PERMANENT YES

PERMANENT YES

PERMANENT YES

CONTRACTUAL NO
FULL TIME NO
PROBATIONARY
 FULL TIME
NO
PROBATIONARY
FULL TIME
NO
PROBATIONARY
FULL TIME
NO
PROBATIONARY
FULL TIME
NO
PROBATIONARY

nue on separate sheet if necessary)

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

REGIONAL ACCREDITATION FOR SPORTS OFFICIATING OFFICIALS 1/4/2017 1/7/2017 40 DEPARTMENT OF EDUCATIO REGION I
RE-ECHO IN THE CONDUCT OF PHYSICAL FITNESS TEST AND SCHOOL 7/9/2016
FITNESS PROGRAM 7/29/2016 24 BINALONAN DISTRICT II

FINE TUNING AND ALIGNMENT OF DRRM PLANS 7/15/2016 7/15/2016 8 DIVISION OF PANGASINAN II

DIVISION SPORTS SCIENCE SEMINAR 8/25/2015 8/27/2015 24 DIVISION OF PANGASINAN II

DISASTER RISK REDUCTION AND MANAGEMENT TRAINING AND
7/9/2015 7/11/2015 24 DIVISION OF PANGASINAN II
SEMINAR
DISTRICT ORIENTATION SEMINAR ON THE IMPLEMENTATIONOF THE
5/28/2015 5/30/215 24 BINALONAN DISTRICT II
DEP.ED RATIONALIZATION
RPMS AND CITIZENS PROGRAM
CHARTER FOR ES AND HS REGIONAL MASS
DEPARTMENT OF EDUCATION
TRAINING OF GRADE 4 TEACHERS ON THE K TO 12 BASIC EDUCATION 5/10/2015 5/16/2015 48
REGION1
PROGRAM
DISTRICT IN SERVICE TRAINING WORKSHOP AND IM REPRODUCTION 10/20/2014 10/22/2014 24 BINALONAN DISTRICT II

SEMINAR WORKSHOP ON TEACHING STRATEGIES AND SIM/MODULE

9/6/2014 9/13/2014 24 DIVISION OF PANGASINAN II
PREPARATION ON EPP
DVISION ENHANCEMENT TRAINING AND ACCREDITATION OF
7/17/2014 7/19/2014 24 DIVISION OF PANGASINAN II
TECHNICAL OFFICIAL,COACHES,TRAINERS AND CHAPERONS

DIVISION SEMINAR CUM DEMONSTRATION ON MUSHROOM CULTURE

10/3/2013 10/3/2013 8 DIVISION OF PANGASINAN II
AND VERMI COMPOSTING

DIVISION ACCREDITATION COURSE FOR DEP.ED

9/8/2013 9/10/2013 24 DIVISION OF PANGASINAN II
SCHOOL SPORTS OFFICIATING OFFICIALS
DIVISION TRAINING IN SPORTS
SCIENCE/PSYCHOLOGY AND SPORTS 8/5/2013 8/7/2013 24 DIVISION OF PANGASINAN II
MEDICINE
SEMINAR DIVISION SPORTS TRAINING FOR
7/26/2013 7/28/2013 24 DIVISION OF PANGASINAN II
CONDITIONING COACHES
DIVISION SPORTS TRAINING FOR OFFICIATING OFFICIALS 7/26/2013 7/26/2013 24 DIVISION OF PANGASINAN II

EMERGING TEACHING STRATEGIES AND PROBLEM

5/192013 5/11/2013 24
SOLVING IN MATHEMATICS ARC ZONE PROFESSIONAL
DEVELOPMENT CENTER
DIVISION SPORTS TRAINING ON CONDITIONING OF
7/5/2013 7/6/2013 16
ATHLETES DIVISION OF PANGASINAN II
 DIVISION SEMINAR ON DISASTER PREPAREDNESS 7/5/2012 7/7/2012
24 DIVISION OF PANGASINAN II
AND CONCIOUSNESS
DISTRICT TRAINING ON FIRST AID APPLICATION 11/9/2012 11/9/2012 8 BINALONAN DISTRICT II

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION 3MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. 3
(Write in full) . (Write in full)

SINGING,DANCING 5TH HONORS IN DIESEL MECHANIC N/A

COOKING,DRIVING ATHLETIC AWARDEE N/A
COMPUTER LITERATE N/A
AUTOMOTIVE REPAIR N/A
ELECTRICAL REPAIR N/A
N/A
N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE 04/24/2017 CS FORM 212 (Revised 2017), Page 3 of 4

 34. Are you related by consanguinity or affinity to the appointing or recommending
authority,
chief or to the
of bureau or office or to the person who has immediate supervision over you in
Bureau
the or Department where you will be apppointed,
Office,
a. within the third degree?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
________________________________
NO
________________________________

35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
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 by any court or tribunal?
If YES, give details:
________________________________
NO
________________________________
37. Have you ever been separated from the service in any of the following modes:
resignation, retirement, dropped from the rolls, dismissal, termination, end of term, If YES, give details:
finished contract or phased out (abolition) in the public or private sector? ________________________________
NO
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last
year (except Barangay election)?
If YES, give details: NO
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 If YES, give details: NO
candidate?
39. Have you acquired the status of an immigrant or permanent resident of another
country?
If YES, give details (country):
NO

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
a. answer
Are you the followingofitems:
a member any indigenous group?
If YES, please specify: NO
b. Are you a person with disability?
If YES, please specify ID No: NO
c. Are you a solo parent?        
If YES, please specify ID No: NO

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

NAME ADDRESS TEL. NO.

ID picture taken within
SAN PABLO the last 6 months
AMADO N. PALAGANAS ,BINALONAN
9397810196 3.5 cm. X 4.5 cm
(passport size)
POBLACION
MARIANO DELOS SANTOS JR. BINALONAN
With full and handwritten
name tag and signature over
printed name
JOE ALMENDARES CATABLAN URDANETA 9255694841
Computer generated
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.
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: UNIFIED MULTI -PURPOSE ID

ID/License/Passport No.: 006-0055-0950

Signature (Sign inside the box)
04/24/2017
Date/Place of Issuance: DAGUPAN CITY,PANGASINAN
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