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 ag
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

I. PERSONAL INFORMATION
2. SURNAME LASPIAS
NAME EXTENSION (JR., SR
FIRST NAME MARIE MICHELLE

MIDDLE NAME DELLATAN

3. DATE OF BIRTH
(mm/dd/yyyy) 12/21/1993 16. CITIZENSHIP Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH ZAMBOANGA CITY If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male Female

6 CIVIL STATUS
Single Married 17. RESIDENTIAL ADDRESS BLOCK 1/ LOT 9
Widowed Separated House/Block/Lot No. S

Other/s:
ROSEWOOD PLAINS SUBD., VILLA K
Subdivision/Village Ba
7. HEIGHT (m) 1.52 BUTUAN AGUSAN
City/Municipality Pr
8. WEIGHT (kg) 50 ZIP CODE 8600

9. BLOOD TYPE O
18. PERMANENT ADDRESS CLUSTER 1
House/Block/Lot No. S

10. GSIS ID NO. N/A LUYAHAN PASO

Subdivision/Village Ba

11. PAG-IBIG ID NO. N/A ZAMBOANGA CITY ZAMBOANGA D

City/Municipality Pr

12. PHILHEALTH NO. 18-250152958-4 ZIP CODE 7000

13. SSS NO. N/A 19. TELEPHONE NO. N/A

14. TIN NO. 482-627-922-000 20. MOBILE NO. 09068994633

15. AGENCY EMPLOYEE NO. F-16010 21. E-MAIL ADDRESS (if any) mariemichellelaspinas@gmail.c

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) N/A
FIRST NAME 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 LASPIAS

NAME EXTENSION (JR., SR)
FIRST NAME JOSELITO
 MIDDLE NAME TUBIL

25. MOTHER'S MAIDEN NAME

SURNAME DELLATAN

FIRST NAME LORNA

MIDDLE NAME ANSOK (Continue on separate sheet if necessary

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY LUYAHAN ELEMENTARY SCHOOL PRIMARY EDUCATION 2000 2006

SECONDARY /
VOCATIONAL AGUSAN NATIONAL HIGH SCHOOL HIGH SCHOOL 2008 2010

TRADE
COURSE
COLLEGE CARAGA STATE UNIVERSITY BS INFORMATION TECHNOLOGY 2010 2015

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE July

CS FORM
L DATA SHEET
erience Sheet shall cause the filing of administrative/criminal case/s against the person

EFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Dual Citizenship

by naturalization

Pls. indicate country:

Street
VILLA KANANGA
Barangay
AGUSAN DEL NORTE
Province
8600

Street
PASONANCA
Barangay
ZAMBOANGA DEL SUR
Province

N/A

09068994633

mariemichellelaspinas@gmail.com

DATE OF BIRTH (mm/dd/yyyy)

N/A
 (Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

1ST HONORABLE
2006 MENTION

2010 NONE

2015 NONE

parate sheet if necessary)

July 3, 2017
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 ap
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

Career Service Professional 82.16 5/3/2015 AGUSAN NATIONAL HIGH SCHOOL N/A

(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.
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

2/9/2016 PRESENT OFFICE ASSISTANT CARAGA STATE UNIVERSITY 6,931.71 N/A JOB ORDER
 (Continue on separate sheet if necessary)

SIGNATURE DATE July 3, 2017

CS FORM 212 (Revised 20
 LICENSE (if applicable)

Date of
Validity

N/A

arate sheet if necessary)

GOV'T
SERVICE

(Y/
N)
Y
arate sheet if necessary)

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 /
From To

N/A N/A N/A N/A

(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/
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To
7th CARAGA REGIONAL ENGINEERING ARCHITECTURE AND TECHNOLOGY CARAGA REG
3/23/2015 3/23/2015 8.00 N/A
EDUCATORS INC. 2015 CONGRESS AND TECHNO
ICT ROADSHOW IN THE NEXT WAVE CITIS: BRINGING ICT OPPORTUNITIES TO
9/19/2013 9/20/2013 16.0 N/A
COUNTRYSIDE FILIPINO TALENTS
 (Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERS
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

COMPUTER LITERATE N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

N/A

eparate sheet if necessary)

ROGRAMS ATTENDED
five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

CARAGA REGIONAL ENGINEERING ARCHITECTURE

AND TECHNOLOGY EDUCATORS INC

CARAGA ICT COUNCIL

eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

N/A

eparate sheet if necessary)

July 3, 2017
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? ________________________________
________________________________
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
341-2296 LOC. the last 6 months
RIZALYN B. DY CARAGA STATE UNIVERSITY
213 3.5 cm. X 4.5 cm
(passport size)
341-2296 LOC.
ROSELLIE C. RACAZA CARAGA STATE UNIVERSITY
213 With full and handwritten
name tag and signature over
341-2296 LOC. printed name
FE J. PATALINGHOG CARAGA STATE UNIVERSITY
213 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: BIR ID

ID/License/Passport No.: 482-627-922-000

Signature (Sign inside the box)
07/03/17
Date/Place of Issuance: 03/18/16
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 o

If YES, give details (country):
, affiant exhibiting his/her validly issued government ID as indicated above.

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