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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 L | E | G | A |S |P | I | | | | | | | | | | | | | | | | | | | | | | | |

FIRST NAME M |I |C | H |E | L |L | E | |A |N | N |E | | | | | | | | | | | | | | | |

MIDDLE NAME V |I | D |A | L | | | | | | | | | | | | | | 3. NAME EXTENSION (e.g. Jr., Sr.)


4. DATE OF BIRTH (mm/dd/yyyy) 03/03/1992 16. RESIDENTIAL ADDRESS

5. PLACE OF BIRTH Maitim, Amadeo, Cavite 2265 Maitim 1st, Amadeo, Cavite
6. SEX Male Female
7. CIVIL STATUS 4119
Single Widowed ZIP CODE

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 / /
EMPLOYER/BUS. NAME / /
BUSINESS ADDRESS / /
TELEPHONE NO. / /
(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 YEAR


GRADUATED
HIGHEST GRADE/ INCLUSIVE DATES OF
28. NAME OF SCHOOL DEGREE COURSE SCHOLARSHIP/
LEVEL/ ATTENDANCE
LEVEL (Write in (Write in full) ACADEMIC HONORS
UNITS EARNED
full) From To RECEIVED
(if not graduated)

Mater Dei Academy (if graduated) 3


ELEMENTARY
Maitim Elementary School 2004 6 June 2001 March 2004 3rd honors

Francisco Perez Tolentino Memorial High


SECONDARY 2008 June 2001 March 2008
VOCATIONAL / School

TRADE
COLLEGE
COURSE Bachelor of Science
in Industrial
TechnologicalUniversity of the Philippines- October
Education Major in 2014 June 2009
Cavite 2014
Computer
Education
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 NUMBER DATE OF
CONFERMENT
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) GOV'T
SERVICE
30. INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY SALARY GRADE
(mm/dd/yyyy) MONTHLY & STEP STATUS OF
SALARY INCREMENT APPOINTMENT
(Write in full) (Write in full) (Format "00-0")
From To
(Yes / No)
07 /21
Present Teacher AWCI de Le Mar 7750 Contractual No
/2016
06 / 01 07 / 20
Teacher Tagaytay City Institute 7750 Contractual No
/2015 /2016

/ / / /

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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
INCLUSIVE DATES
31. NAME & ADDRESS OF ORGANIZATION NUMBER OF
(Write in full) (mm/dd/yyyy) POSITION / NATURE OF WORK
HOURS
From 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 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 Cavite Alliance of Private
07 / 23 /2016 07 / 24 /2016 16 hours
Hands Schools, Inc.

Technological University of the


Basic Technical Skills Training Out-Campus Program 02 /16 /2013 03 / 09 /2013 32 hours
Philippines/Brgy. Sta. Lucia

/ / / /

/ / / /

/ / / /

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(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION: ASSOCIATION/ORGANIZATION
33. SPECIAL SKILLS / HOBBIES: 34. 35.
(Write in full)
(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): YES NO


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

b. Within the fourth degree (for Local Government Employees): YES NO


appointing authority or recommending authority where you will be appointed? If YES, give details:
_____________________________________
_____________________________________
_____________________________________
37 a. Have you ever been formally charged? YES NO
If YES, give details: √
________________________________
________________________________ √
b. Have you ever been guilty of any administrative offense? YES NO
If YES, give details:
________________________________
________________________________
38. Have you ever been convicted of any crime or violation of any law, decree, ordinance or YES NO
regulation by any court or tribunal? If YES, give details:
________________________________
________________________________
39. 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, AWOL or
phased out, in the public or private sector? If YES, give details:
________________________________
________________________________

40. 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? YES NO


If YES, please specify: ____________________
b. Are you differently abled? YES NO
If YES, please specify: ____________________
c. Are you a solo parent? YES NO
If YES, please specify: Not yet Married
42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)

NAME ADDRESS TEL. NO.

Mrs. Mariechelle Batino Tagaytay City, Cavite 9328623417


ID picture taken within
the last 6 months
3.5 cm. X 4.5 cm
(passport size)

Computer generated
43. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and or xerox copy of picture
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable

Philippines.

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

LEGASPI, MICHELLE ANNE VIDAL - T15099015 CS FORM 212 (Revised 2005), Page 4 of 4

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