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/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 VIZCARRA
NAME EXTENSION (JR., SR)
FIRST NAME DWIGHT KAYCE

MIDDLE NAME EÑOSA

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
5/4/1995 by by
✘
birth naturalization
4. PLACE OF BIRTH LOPEZ, QUEZON If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS DON MARIANO SAN JOSE
House/Block/Lot No. Street
Separate
Widowed POBLACION
Other/s: d Subdivision/Village Barangay

7. HEIGHT (m) 1.75 BUENAVISTA QUEZON

City/Municipality Province
8. WEIGHT (kg) 77 ZIP CODE 4320

9. BLOOD TYPE B-
18. PERMANENT ADDRESS DON MARIANO SAN JOSE
House/Block/Lot No. Street

10. GSIS ID NO. N/A POBLACION

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1212-0064-3837 BUENAVISTA QUEZON

City/Municipality Province

12. PHILHEALTH NO. 08-026047790-4 ZIP CODE 4320

13. SSS NO. 34-6447176-4 19. TELEPHONE NO. N/A

14. TIN NO. 497-298-031-000 20. MOBILE NO. 09498220850

15. AGENCY EMPLOYEE NO. 6319682 21. E-MAIL ADDRESS (if any) dwightkayce.vizcarra@deped.gov.ph
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 SHEN IRIDESSA G. VIZCARRA 7/28/2018

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24 FATHER'S SURNAME VIZCARRA

NAME EXTENSION (JR., SR)
FIRST NAME FERDINAND

MIDDLE NAME ROLDAN

25 MOTHER'S MAIDEN NAME

SURNAME EÑOSA

FIRST NAME EVANGELINE

MIDDLE NAME BELLEZA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

BUENAVISTA CENTRAL ELEMENTARY SALUTATO

ELEMENTARY PRIMARY EDUCATION 2001 2007 GRADUATED 2007
SCHOOL RIAN
VALEDICTO
SECONDARY /
VOCATIONAL BUENAVISTA NATIONAL HIGH SCHOOL HIGH SCHOOL 2007 2011 GRADUATED 2011
RIAN
PHILIPPINE INSTITUTE FOR ARTS VISUAL AND GRAPHICS DESIGN
2017 2017 GRADUATED 2017 PASSER
AND TRADE - GUMACA NC III
TRADE
COURSE PHILIPPINE NORMAL UNIVERSITY - BACHELOR IN SECONDARY EDUCATION CUM
COLLEGE
(MAJOR IN SOCIAL SCIENCE)
2011 2015 GRADUATED 2015
SOUTH LUZON LAUDE

GRADUATE STUDIES N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 2/03/2020 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 82.20 9/27/2015 LUCENA CITY 1421765 5/4/2018

(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
SERVICE
28. INCLUSIVE DATES SALARY/ JOB/ PAY
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)
7/3/2017 present Teacher I Buenavista National High School JHS 20,754 11-1 Regular Y

6/1/2016 3/31/2017 Volunteer ALS Lopez West District N/A N/A Regular N

4/1/2015 5/31/2016 Instructor/Technical Staff The Personage Institute 5000 N/A Regular N

(Continue on separate sheet if necessary)

SIGNATURE DATE 02/03/2020 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

Alternative Learning System, Lopez West District 1/7/2016 5/25/2017 664.0 Barangay Literacy Worker Volunteer

(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

Division Orientation on DepEd DCP 12/13/2019 12/13/2019 8 Technical DepEd Division of Quezon

Division Training on Open Educational Resource 11/24/2019 11/26/2019 24 Technical DepEd Division of Quezon; DepEd-OER

Tech4Ed Seminar Workshop of DICT 10/09/2019 10/11/2019 24 Technical DepEd Division of Quezon; DICT

Division Seminar Workshop on IPED Instructional Materials 11/07/2018 11/07/2019 72 Technical DepEd Division of Quezon

Division Seminar Workshop on SHS Curriculum Integration 12/6/2018 12/8/2018 24 Technical DepEd Division of Quezon

Division LIS/EBEIS Orientation 2017 2019 24 Technical DepEd Division of Quezon

Division Teachers Induction Program 9/5/2017 11/27/2019 48 Instructional DepEd Division of Quezon

Midterm In Service Training for Teachers 2017 2019 120 Instructional DepEd BNHS

Summer In Service Training for Teachers 2018 2019 80 Instructional DepEd BNHS

Division Seminar Workshop for Campus Journalism 09/08/2017 09/09/2017 24 Instructional DepEd Division of Quezon
National Seminar/Workshop/Training on 21st Century Teaching Strategies and SKA Review, Training and Professional
04/21/2017 4/23/2017 24 Instructional
Best Practices and Innovative Instructional Materials Development Center Inc.

(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 full)
(Write in full)

Computer literate and can operate various Member, SKA Review, Training and
Excellence in Information Communications and Technology
computer programs Professional Development Center Inc.
Able to troubleshoot computer software Member, IT Org. and Technical Working
Excellence in Research
related problems Group, PNU South Luzon

(Continue on separate sheet if necessary)

SIGNATURE DATE 02/03/2020 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 ✘ NO
YES
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:
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
SAN RAFAEL ST., BRGY. TALOLONG, the last 6 months
JOANNE MARGRET F. MAÑAGO LOPEZ, QUEZON
9182228498 3.5 cm. X 4.5 cm
(passport size)

CHARITO E. AVILA BRGY. MAGSAYSAY, LOPEZ, QUEZON 9196670248 With full and handwritten
name tag and signature over
BRGY. VILLAHERMOSA, LOPEZ, printed name
CYREN D. OSEÑA QUEZON
9187139797
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 ID
ID/License/Passport No.: 1421765 Signature (Sign inside the box)
2/03/2020
Date/Place of Issuance: 12/28/2017 LUCENA CITY Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this 3rd day of February, 2020 , affiant exhibiting his/her validly issued government ID as indicated above.

MARITA A. PENTINIO
Person Administering Oath

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