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CS FORM 212 (Revised 2005) Unique Applicant Number PERSONAL DATA SHEET T15099015 Print legibly. Mark appropriate
CS FORM 212 (Revised 2005)
Unique Applicant Number
PERSONAL DATA SHEET
T15099015
Print legibly. Mark appropriate boxes
with "
" and use separate sheet if necessary.
1. CS ID No.
(to be filled up by CSC)
I. PERSONAL INFORMATION
2. SURNAME
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FIRST NAME
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3. NAME EXTENSION (e.g. Jr., Sr.)
16. RESIDENTIAL ADDRESS
4.
MIDDLE NAME
DATE OF BIRTH (mm/dd/yyyy)
03/03/1992
5.
PLACE OF BIRTH
Maitim, Amadeo, Cavite
2265
Maitim 1st, Amadeo, Cavite
6.
SEX
Male
Female
7.
CIVIL STATUS
Single
Widowed
ZIP CODE
4119
Married
Separated
17. TELEPHONE NO.
(+639) 266942145
Annulled
Others, specify ___________
18. PERMANENT ADDRESS
8. CITIZENSHIP
Filipino
2265
Maitim 1st, Amadeo, Cavite
9.
HEIGHT (m)
5'4"
10.
WEIGHT (kg)
40 kg
ZIP CODE
4119
11.
BLOOD TYPE
AB
19. TELEPHONE NO.
(+639) 266942145
12.
GSIS ID NO.
20. E-MAIL ADDRESS (if any)
michelleanne.legaspi@yahoo.com
13.
PAG-IBIG ID NO.
21. CELLPHONE NO. (if any)
(+639)151769608
14.
PHILHEALTH NO.
22. AGENCY EMPLOYEE NO.
15.
SSS NO.
34-5819338-8
23.
TIN
483-364-762
II. FAMILY BACKGROUND
24.
SPOUSE'S SURNAME
25. NAME OF CHILD (Write full name and list all)
DATE OF BIRTH (mm/dd/yyyy)
FIRST NAME
Bawar, James Nathaniel Legaspi
12/09/2011
MIDDLE NAME
/ /
OCCUPATION
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EMPLOYER/BUS. NAME
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BUSINESS ADDRESS
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TELEPHONE NO.
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/
(Continue on separate sheet if necessary)
/ /
26.
FATHER'S SURNAME
Legaspi
10/16/1956
FIRST NAME
Felicisimo
MIDDLE NAME
Baurile
27.
MOTHER'S MAIDEN NAME
07/22/1958
SURNAME
Vidal
FIRST NAME
Consuelo
MIDDLE NAME
Austria
(Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
28.
NAME OF SCHOOL
INCLUSIVE DATES OF
ATTENDANCE
SCHOLARSHIP/
LEVEL
(Write in
DEGREE COURSE
(Write in full)
ACADEMIC HONORS
full)
HIGHEST GRADE/
LEVEL/
UNITS EARNED
(if not graduated)
RECEIVED
From
To
Mater Dei Academy
3
ELEMENTARY
Maitim Elementary School
2004
6
June 2001
March 2004
3rd honors
SECONDARY
Francisco Perez Tolentino Memorial High
School
2008
June 2001
March 2008
TRADE
COLLEGE
TechnologicalUniversity of the Philippines-
Cavite
Bachelor of Science
in Industrial
Education Major in
Computer
Education
October
2014
June 2009
2014
GRADUATE STUDIES
(Continue on separate sheet if necessary)
LEGASPI, MICHELLE ANNE VIDAL - T15099015
Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY

 

29.

 

DATE OF

 

LICENSE (if applicable)

 

CAREER SERVICE/ RA 1080 (BOARD/ BAR)

 

RATING

EXAMINATION /

PLACE OF EXAMINATION / CONFERMENT

   

UNDER SPECIAL LAWS/ CES/ CSEE

CONFERMENT

NUMBER

DATE OF

RELEASE

         

12/21/201

Licensure Examination for Teachers-Secondary

76.20%

09/27/2015

Manila, Philippines

1414567

5

           
           
           
           
           
           
 

(Continue on separate sheet if necessary)

 

V. WORK EXPERIENCE (Include private employment. Start from your current work)

 

30.

INCLUSIVE DATES

 

POSITION TITLE

DEPARTMENT / AGENCY / OFFICE / COMPANY

 

SALARY GRADE

 

SERVICE

(mm/dd/yyyy)

MONTHLY

& STEP

STATUS OF

 

(Write in full)

 

(Write in full)

SALARY

INCREMENT

APPOINTMENT

From

   

To

(Format "00-0")

07

/21

/2016

Present

   

Teacher

 

AWCI de Le Mar

   

Contractual

  • 7750 No

 

06

/2015

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01

07

/2016

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20

 

Teacher

Tagaytay City Institute

   

Contractual

  • 7750 No

 

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(Continue on separate sheet if necessary)

 

LEGASPI, MICHELLE ANNE VIDAL - T15099015

 

CS FORM 212 (Revised 2005), Page 2 of 4

 

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

  • 31. NAME & ADDRESS OF ORGANIZATION

INCLUSIVE DATES

 

NUMBER OF

 
 

(Write in full)

(mm/dd/yyyy)

 

HOURS

 

POSITION / NATURE OF WORK

   

From

 

To

 
   

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(Continue on separate sheet if necessary)

 

VII. TRAINING PROGRAMS (Start from the most recent training.)

 
 

INCLUSIVE DATES OF ATTENDANCE

   
  • 32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write

NUMBER OF

CONDUCTED/ SPONSORED BY

in full)

 

(mm/dd/yyyy)

 

HOURS

 

(Write in full)

 

From

 

To

 

SHS et al: It's Never Too Late to Learn-the Fate of K-12 Lies in your Hands

  • 07 /

23

/2016

07

/ 24 /2016

  • 16 hours

Cavite Alliance of Private Schools, Inc.

Basic Technical Skills Training Out-Campus Program

 
  • 02 /16 /2013

03 / 09 /2013

  • 32 hours

Technological University of the Philippines/Brgy. Sta. Lucia

         
   

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(Continue on separate sheet if necessary)

 

VIII. OTHER INFORMATION

 

NON-ACADEMIC DISTINCTIONS / RECOGNITION:

   

MEMBERSHIP IN ASSOCIATION/ORGANIZATION

  • 33. SPECIAL SKILLS / HOBBIES:

34.

(Write in full)

35.

   

(Write in full)

Computer Literate

   

Art Works

   

Cooking

   
     
     
 

(Continue on separate sheet if necessary)

 

LEGASPI, MICHELLE ANNE VIDAL - T15099015

CS FORM 212 (Revised 2005), Page 3 of 4

 
 
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S 31. NAME
36. a. b.
36.
a.
b.

37 a. Have you ever been formally charged?

36. a. b. a. Have you ever been formally charged? NO YES YES NO NO NO
36. a. b. a. Have you ever been formally charged? NO YES YES NO NO NO
36. a. b. a. Have you ever been formally charged? NO YES YES NO NO NO
NO YES YES NO
NO
YES
YES
NO
NO NO YES YES
NO
NO
YES
YES

If YES, give details:

36. a. b. a. Have you ever been formally charged? NO YES YES NO NO NO
36. a. b. a. Have you ever been formally charged? NO YES YES NO NO NO

Are you related by consanguinity or affinity to any of the following :

Within the third degree (for National Government Employees):

appointing authority, recommending authority, chief of office/bureau/department or person who has immediate supervision over you in the Office, Bureau or Department where you will be appointed?

Within the fourth degree (for Local Government Employees):

appointing authority or recommending authority where you will be appointed?

If YES, give details:

_____________________________________

_____________________________________

_____________________________________

If YES, give details:

_____________________________________

_____________________________________

_____________________________________

________________________________

________________________________

If YES, give details:

________________________________

________________________________

NO YES
NO
YES
_____________________________________ _____________________________________ _____________________________________ ________________________________ ________________________________ If YES, give details: ________________________________ ________________________________ NO YES If YES, give
_____________________________________ _____________________________________ _____________________________________ ________________________________ ________________________________ If YES, give details: ________________________________ ________________________________ NO YES If YES, give

If YES, give details:

________________________________

________________________________

  • ________________________________ ________________________________

If YES, give details:

NO YES
NO
YES

If YES, give details:

________________________________

________________________________

YES YES NO NO NO YES
YES
YES
NO
NO
NO
YES
NO YES If YES, give details: ________________________________ ________________________________ YES YES NO NO NO YES If
NO YES If YES, give details: ________________________________ ________________________________ YES YES NO NO NO YES If

If YES, please specify: ____________________

If YES, please specify: ____________________

If YES, please specify: Not yet Married

If YES, please specify: ____________________ If YES, please specify: Not yet Married TEL. NO. 9328623417 ID
TEL. NO.
TEL. NO.
9328623417
9328623417
If YES, please specify: ____________________ If YES, please specify: Not yet Married TEL. NO. 9328623417 ID
If YES, please specify: ____________________ If YES, please specify: Not yet Married TEL. NO. 9328623417 ID
If YES, please specify: ____________________ If YES, please specify: Not yet Married TEL. NO. 9328623417 ID
ID picture taken within the last 6 months 3.5 cm. X 4.5 cm (passport size) Computer
ID picture taken within the last 6 months 3.5 cm. X 4.5 cm (passport size) Computer
ID picture taken within the last 6 months 3.5 cm. X 4.5 cm (passport size)
ID picture taken within
the last 6 months
3.5 cm. X 4.5 cm
(passport size)
ID picture taken within the last 6 months 3.5 cm. X 4.5 cm (passport size) Computer
ID picture taken within the last 6 months 3.5 cm. X 4.5 cm (passport size) Computer
ID picture taken within the last 6 months 3.5 cm. X 4.5 cm (passport size) Computer
Computer generated or xerox copy of picture is not acceptable PHOTO
Computer generated
or xerox copy of picture
is not acceptable
PHOTO

RIGHT THUMBMARK

RIGHT THUMBMARK

b. Have you ever been guilty of any administrative offense?

Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal?

Have you ever been separated from the service in any of the following modes: resignation, retirement,

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, finished contract, AWOL or phased out, in the public or private sector?

Have you ever been separated from the service in any of the following modes: resignation, retirement,

Have you ever been a candidate in a national or local election (except Barangay election)?

b. Have you ever been guilty of any administrative offense? Have you ever been convicted of
b. Have you ever been guilty of any administrative offense? Have you ever been convicted of

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:

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

ADDRESS
ADDRESS
Tagaytay City, Cavite
Tagaytay City, Cavite
b. Have you ever been guilty of any administrative offense? Have you ever been convicted of
b. Have you ever been guilty of any administrative offense? Have you ever been convicted of
b. Have you ever been guilty of any administrative offense? Have you ever been convicted of
38.
38.
39.
39.
40.
40.
a. Are you a member of any indigenous group? b. Are you differently abled? c. Are
a. Are you a member of any indigenous group?
b. Are you differently abled?
c. Are you a solo parent?
41.
42.
42.
NAME
NAME
Mrs. Mariechelle Batino
Mrs. Mariechelle Batino
NAME Mrs. Mariechelle Batino 43. I I
NAME Mrs. Mariechelle Batino 43. I I
43. I I
43.
I
I

declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines.

also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust that this information shall remain confidential.

01/05/2015

ISSUED ON (mm/dd/yyyy)

City of Bacoor

ISSUED AT

27229478

COMMUNITY TAX CERTIFICATE NO.

01/05/2015 ISSUED ON (mm/dd/yyyy) City of Bacoor ISSUED AT 27229478 COMMUNITY TAX CERTIFICATE NO. LEGASPI, MICHELLE

LEGASPI, MICHELLE ANNE VIDAL - T15099015

36. a. b. a. Have you ever been formally charged? NO YES YES NO NO NO
SIGNATURE (Sign inside the box) DATE ACCOMPLISHED 07/08/2016
SIGNATURE (Sign inside the box)
DATE ACCOMPLISHED
07/08/2016
SIGNATURE (Sign inside the box) DATE ACCOMPLISHED 07/08/2016
SIGNATURE (Sign inside the box) DATE ACCOMPLISHED 07/08/2016
SIGNATURE (Sign inside the box) DATE ACCOMPLISHED 07/08/2016
SIGNATURE (Sign inside the box) DATE ACCOMPLISHED 07/08/2016
SIGNATURE (Sign inside the box) DATE ACCOMPLISHED 07/08/2016
SIGNATURE (Sign inside the box) DATE ACCOMPLISHED 07/08/2016
36. a. b. a. Have you ever been formally charged? NO YES YES NO NO NO
36. a. b. a. Have you ever been formally charged? NO YES YES NO NO NO

CS FORM 212 (Revised 2005), Page 4 of 4

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