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 DIAZ
NAME EXTENSION (JR., SR)
FIRST NAME NELSON

MIDDLE NAME ANTING

3. DATE OF BIRTH
08/03/1994 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
✘
by by
birth naturalization
4. PLACE OF BIRTH Brgy. Poblacion, San Francisco SDN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female
Single 17. RESIDENTIAL ADDRESS
6 CIVIL STATUS ✘ Married
House/Block/Lot No. Street
Widowed Separate PUROK BAYBAYON POBLACION
Other/s: d Subdivision/Village Barangay
SAN FRANCISCO SURIGAO del NORTE
7. HEIGHT (m) 1.62
City/Municipality Province
8. WEIGHT (kg) 65 ZIP CODE 8400

18. PERMANENT ADDRESS

9. BLOOD TYPE O+
House/Block/Lot No. Street
PUROK BAYBAYON POBLACION
10. GSIS ID NO. N/A
Subdivision/Village Barangay
SAN FRANCISCO SURIGAO del NORTE
11. PAG-IBIG ID NO. 1212-7400-4020
City/Municipality Province

12. PHILHEALTH NO. 12-051602415-7 ZIP CODE 8400

13. SSS NO. 08-2937236-2 19. TELEPHONE NO. N/A

14. TIN NO. 766-744-146-00000 20. MOBILE NO. 09473416123

15. AGENCY EMPLOYEE NO. LVRO-022 21. E-MAIL ADDRESS (if any) nelsonantingdiaz@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)

FIRST NAME N/A

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

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME DIAZ

NAME EXTENSION (JR., SR)
FIRST NAME ARNEL

MIDDLE NAME LOQUIAS

25. MOTHER'S MAIDEN NAME

SURNAME ANTING

FIRST NAME ROSALIA

MIDDLE NAME SILVOSA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY MACOPA ELEMENTARY SCHOOL 6/1/2003 3/15/2008 2008 VALEDICTORIAN

SECONDARY
VOCATIONAL / SAN FRANCISCO NATIONAL HIGH SCHOOL 6/1/2008 3/27/2011 2011 VALEDICTORIAN

N/A

TRADE
COURSE
COLLEGE SURIGAO STATE COLLEGE OF TECHNOLOGY Bachelor of Science in CIVIL ENGINEERING 6/3/2011 5/30/2018 2018

GRADUATE STUDIES 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
NOVEMBER 10-11,
CIVIL ENGINEER BOARD EXAMINATION 2018
UNIVERSITY OF CEBU, BANILAD 0168611 8/3/2022

NOVEMBER 6-7,
DRIVER'S LICENSE (Non-Professional) EXAM 2019
MANDAUE CITY LICENSING CENTER G0619010510 8/3/2024

(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)

1/9/2019 1/9/2021 PROJECT ENGINEER LVRO CONSTRUCTION AND SUPPLY 21,320.00 Regular

(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
SURIGAO STATE COLLEGE OF TECHNOLOGY COMMUNITY EXTENSION HELPER/ CONSTRUCTION OF MAMANWA
5/1/2017 5/2/2017 16.0
PROGRAM @ BRGY. JUBGAN, SAN FRANCISCO SURIGAO DEL NORTE TRIBE MUTIPURPOSE GYM

(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) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To

(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)

DRAWING USING AUTOCAD

PROJECT COST ESTIMATES

PAINTING

CHARCOAL PAINTING

EDITORIAL CARTOONING

BASKETBALL/VOLLEYBALL

(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 ✘ 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? RESIGNATION, LOOKING FOR NEW WORK
________________________________
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 YES ✘ NO
last 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 CONTACT NO.

ID picture taken within
the last 6 months
Engr. Allan G. Marcillones, LVRO Const. Manager Cebu City 09516359561 4.5 cm. X 3.5 cm
(passport size)

Engr. Kevin Mike Simblante, Engineer II, VSMMC San Francisco, Surigao del Norte 09488215073
Computer generated
or photocopied picture
Genlie P. Amper, Former Fronline Associate, WU San Francisco, Surigao del Norte 09675597355 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

ID/License/Passport No.: 0168611 Signature (Sign inside the box)

Date/Place of Issuance: PRC CEBU 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