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CS FORM 212 (Revised 2005)

Unique Applicant Number

PERSONAL DATA SHEET


Print legibly. Mark appropriate boxes

with "

T15099015

1. CS ID No.

" and use separate sheet if necessary.

(to be filled up by CSC)

I. PERSONAL INFORMATION
L | E

2. SURNAME

| G | A |S

|P

| L |L

FIRST NAME

|I

|C

| H

MIDDLE NAME

|I

| D

|A

|E
| L |

| E |
|

|A
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|N
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| N

|E

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Maitim, Amadeo, Cavite


Male

6. SEX
7. CIVIL STATUS

Married

Separated

Annulled

Others, specify ___________ 18. PERMANENT ADDRESS

Filipino
5'4"

10. WEIGHT (kg)

40 kg

11. BLOOD TYPE

AB

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| 3. NAME EXTENSION (e.g. Jr., Sr.)

ZIP CODE

4119
(+639) 266942145

17. TELEPHONE NO.

2265 Maitim 1st, Amadeo, Cavite

ZIP CODE

4119

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.


15. SSS NO.

2265 Maitim 1st, Amadeo, Cavite

Widowed

9. HEIGHT (m)

Female

Single

8. CITIZENSHIP

16. RESIDENTIAL ADDRESS

03/03/1992

4. DATE OF BIRTH (mm/dd/yyyy)


5. PLACE OF BIRTH

| I

22. AGENCY EMPLOYEE NO.

483-364-762

23. TIN

34-5819338-8

II. FAMILY BACKGROUND


24. SPOUSE'S SURNAME

25. NAME OF CHILD (Write full name and list all)

DATE OF BIRTH (mm/dd/yyyy)

Bawar, James Nathaniel Legaspi

FIRST NAME

12/09/2011
/

OCCUPATION

EMPLOYER/BUS. NAME

BUSINESS ADDRESS

MIDDLE NAME

TELEPHONE NO.
(Continue on separate sheet if necessary)
26. FATHER'S SURNAME

10/16/1956

Legaspi

FIRST NAME

Felicisimo

MIDDLE NAME

Baurile

07/22/1958

27. MOTHER'S MAIDEN NAME


SURNAME

Vidal

FIRST NAME

Consuelo

MIDDLE NAME

Austria

(Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND


28.

YEAR
GRADUATED

NAME OF SCHOOL
LEVEL

(Write in

HIGHEST GRADE/
LEVEL/
UNITS EARNED
(if not graduated)

DEGREE COURSE
(Write in full)

From

To

SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED

June 2001

March 2004

3rd honors

2008

June 2001

March 2008

2014

June 2009

October
2014

full)

(if graduated)

Maitim Elementary School

2004

Francisco Perez Tolentino Memorial High


School

Mater Dei Academy


ELEMENTARY

SECONDARY
VOCATIONAL /

COLLEGE
COURSE

TRADE

TechnologicalUniversity of the PhilippinesCavite

Bachelor of Science
in Industrial
Education Major in
Computer
Education

INCLUSIVE DATES OF
ATTENDANCE

GRADUATE STUDIES

(Continue on separate sheet if necessary)


LEGASPI, MICHELLE ANNE VIDAL - T15099015

Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY


29.

CAREER SERVICE/ RA 1080 (BOARD/ BAR)


UNDER SPECIAL LAWS/ CES/ CSEE

RATING

Licensure Examination for Teachers-Secondary 76.20%

DATE OF
EXAMINATION /
CONFERMENT

09/27/2015

LICENSE (if applicable)


PLACE OF EXAMINATION / CONFERMENT

Manila, Philippines

NUMBER

1414567

DATE OF
RELEASE

12/21/201
5

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work)
30.

INCLUSIVE DATES
(mm/dd/yyyy)
From

POSITION TITLE

DEPARTMENT / AGENCY / OFFICE / COMPANY


(Write in full)

To

(Write in full)

GOV'T
SERVICE
MONTHLY
SALARY

SALARY GRADE
& STEP
INCREMENT
(Format "00-0")

STATUS OF
APPOINTMENT
(Yes / No)

07 /21
/2016

Present

Teacher

AWCI de Le Mar

7750

Contractual No

06 / 01
/2015

07 / 20
/2016

Teacher

Tagaytay City Institute

7750

Contractual No

/
(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
(Write in full)

NUMBER OF
HOURS

(mm/dd/yyyy)
From

POSITION / NATURE OF WORK

To

(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
in full)

(mm/dd/yyyy)
From

NUMBER OF
HOURS

CONDUCTED/ SPONSORED BY
(Write in full)

To

SHS et al: It's Never Too Late to Learn-the Fate of K-12 Lies in your
07 / 23 /2016
Hands

07 / 24 /2016 16 hours

Cavite Alliance of Private


Schools, Inc.

Basic Technical Skills Training Out-Campus Program

03 / 09 /2013 32 hours

Technological University of the


Philippines/Brgy. Sta. Lucia

02 /16 /2013

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


33.

SPECIAL SKILLS / HOBBIES:

34.

NON-ACADEMIC DISTINCTIONS / RECOGNITION:


(Write in full)

35.

MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(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

36.

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

a.

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?

YES
NO
If YES, give details:
_____________________________________
_____________________________________
_____________________________________

b.

Within the fourth degree (for Local Government Employees):


appointing authority or recommending authority where you will be appointed?

YES
NO
If YES, give details:
_____________________________________
_____________________________________
_____________________________________

37

a. Have you ever been formally charged?

YES

NO

If YES, give details:


________________________________
________________________________
YES

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

NO

If YES, give details:


________________________________
________________________________
38.

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

39.

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?

40.

YES
NO
If YES, give details:
________________________________
________________________________
YES

NO

If YES, give details:


________________________________
________________________________

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

YES

NO

If YES, give details:


________________________________
________________________________
41.

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?

b.

Are you differently abled?

c.

Are you a solo parent?

YES
NO
If YES, please specify: ____________________
YES
NO
If YES, please specify: ____________________
YES
NO
If YES, please specify: Not yet Married

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


NAME

Mrs. Mariechelle Batino

43.

ADDRESS

TEL. NO.

Tagaytay City, Cavite

9328623417

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

ID picture taken within


the last 6 months
3.5 cm. X 4.5 cm
(passport size)
Computer generated
or xerox copy of picture
is not acceptable

PHOTO

27229478
COMMUNITY TAX CERTIFICATE NO.

City of Bacoor
ISSUED AT

SIGNATURE (Sign inside the box)

01/05/2015

07/08/2016

ISSUED ON (mm/dd/yyyy)

DATE ACCOMPLISHED

LEGASPI, MICHELLE ANNE VIDAL - T15099015

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

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