Republic of the Philippines Department of the Interior and Local Government NATIONAL HEADQUARTERS PHILIPPINE NATIONAL POLICE Camp
Crame, Quezon City TIN No: Badge No: PSMBFI:
WARNING: The correctness of the statement of entries made herein is subject to verification and any deliberate omission or distortion of information may give sufficient cause for investigation. Date Accomplished: __________________
I. GENERAL INFORMATION
1. NAME (Last Name, First Name, Middle Name Qualifier) 2. RANK 5. UNIT STATION/ADDRESS 7. HOME ADDRESS (House No/Street/Municipalities/City/Province 8. DATE OF BIRTH 10. SEX 13. COLOR OF HAIR 17. Blood type 20. IDENTIFYING MARKS 9. PLACE OF BIRTH 11. CIVIL STATUS 14. COLOR OF EYES 18. BUILD 21. LANGUAGE (Read, Write, Speak) 15. HEIGHT (cm) 12. RELIGION 16. WEIGHT (kg) 19. COMPLEXION 22. ETHNIC GROUP 24. OCCUPATION 3. DESIGNATION 4. DATE DESIGNATED 6. TELEPHONE NUMBER
23. NAME AND ADDRESS OF SPOUSE/NEAREST KIN 25. DEPENDENTS NAME
AGE
REALTIONSHIP
ADDRESS
26. HOUSING DATA OWN HOUSE & LOT RENT HOUSE OCCUPYING GOVT QTRS
OWN HOUSE ONLY
RENT ROOM
OTHERS (Specify)
____________________________________
Signature
II. APPOINTMENT DATA
27.EFFECTIVE DATE OF PREVIOUS RANK BY CSC: STATUS TEMPORARY PERMANENT 29.EFFECTIVE DATE OF PRESENT RANK BY CSC: STATUS TEMPORARY PERMANENT APPOINTMENT OF APPOINTMENT OF 28. EFFECTIVE DATE OF PROMOTION OF PREVIOUS RANK PER PNP SO/GO STATUS TEMPORARY PERMANENT 30.EFFECTIVE DATE OF PROMOTION OF PRESENT RANK PER PNP SO/GO STATUS TEMPORARY PERMANENT DATE _____________ _____________ DATE
DATE
DATE ______________ ______________
31. IF PRESENT RANK PASSED TEMPORARY, STATE REASON [ ] Eligibility [ ] TIG [ ] Training [ [ Others ________
33. DATE SATISFIED THE DEFICIENCY: DEFICIENCY _______________ (Specify) MONTH/YEAR _______________
FOR POLICE COMMISSIONED OFFICERS ONLY 36. SOURCE OF COMMISSION/ENTRY TO THE PNP [ [ ] AFP Regular ] CIS [ [ ] AFP Reserve ] Lateral Entry [ [ ] INP ] Original PNP [ ] NAPOLCOM
III. EDUCATIONAL BACKGROUND
LEVEL
NAME OF SCHOOL
LOCATION
INCLUSIVE DATES
DEGREE COMPLETED
HONOR RECEIVED
IV. POLICE MILITARY TRAINING/SCHOLARSHIP COURSE
COURSE TAKEN DATE LOCATION CONDUCTED BY
_________________________________
Signature
V. NAPOLCOM/ CIVIL SERVICE/PRC ELIGIBILITIES
TITLE OF EXAM DATE TAKEN WHERE TAKEN RATING OBTAINED
VI. PERFORMANCE EVALUATION RATING
RATING PERIOD (Immediately preceding two (2) semesters) RATING RATER
VII. PHYSICAL FITNESS TEST RATING
RATING PERIOD (Immediately preceding two (2) semesters) RATING CONDUCTED BY
VIII. STATEMENT OF ASSETS & LIABILITIES, NETWORTH
FISCAL PERIOD (Immediately preceding three (3) fiscal year) TOTAL ASSET TOTAL LIABILITIES NET WORTH
IX INDIVIDUAL INCOME TAX RECORDS
FISCAL PERIOD (Immediately preceding three (3) fiscal year) GROSS INCOME TAXABLE INCOME INCOME TAX PAID
X. OFFENSE DATA
OFFENSE COMMITTED AS CHARGED (State whether administrative or criminal) TYPE OF CHARGE (Principal or what) STATUS/DISPOSITION (Exonerated, etc; penalty)
XI. DATA ON PREVIOUS RETIREMENT/DISMISSAL/SUSPENSION
Have you ever been retired, dismissed, forced to resign or suspended from any employment for reason other than luck of funds? [ ] YES [ ] NO If yes, give particulars _________________________
Have you ever been a candidate in a national or local election (including Barangay election)? [ ] YES POSITION [ ] NO If yes, give particulars _________________________ PLACE DATE
_______________________
Signature
XII. PHYSICAL AND MEDICAL RECORDS
DATE OF LAST MEDICAL EXAMINATION: DATE OF LAST DENTAL EXAMINATION: WHERE TAKEN WHERE TAKEN
DATE OF LAST NP EXAMINATION: DATE OF LASTDRUG TEST: DATE OF LAST PFT:
WHERE TAKEN WHERE TAKEN WHERE TAKEN
XIII. POLICE/MLITARY MAJOR DESIGNATION
POLICE/DESIGNATION UNIT/OFFICE INCLUSIVE DATES
XIV. PROMOTION RECORDS
OLD RANK NEW RANK EFFECTIVITY DATE PROMOTION STATUS AUTHORITY
XV. OTHER COURSE TRAINING/SEMINARS ( In Present Rank)
COURSE TAKEN DATE TRAINING HOURS SCHOOL LOCATION HONORS RECEIVED
_______________________________________
Signature
XVI. FIREARMS RECORDS
MR/LIC. NO KIND MAKE CALIBER AMMO ISSUING
XVII. AWARDS AND RECOGNITIONS RECEIVED (In Present Rank)
NATURE OF AWARD DATE AWARDED AUTHORITY
INDIVIDUAL AND UNIT CITATION BADGE
INDIVIDUAL AND UNIT AWARDS/STREAMERS
LETTER OF COMMENDATIONS/PLAQUES/CERTIFICATES OF APPRECIATION/COMMENDATIONS/MERITS (Not yet converted to PNP Medals)
ACADEMIC AWARDS
_______________________________________
Signature
XVIII. CERTIFICATION
THIS IS TO CERTIFY that the answers given above are true and correct to the best of my knowledge and belief. I COMMIT MYSELF TO BE LIABLE for perjury and/or dishonesty as a result of any false. Misrepresentation or
omission in this Personal Data Sheet
SIGNATURE OVER PRINTED NAME
THUMBMARK `
SUBSCRIBED AND SWORN to before me this ___________ ________________, 2012 at _________________________________, Philippines.
day
of
_____________________________________ (Administering Officer)
NHQ/NSU/PRO Official Seal
Not valid without Notarial Seal
