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PERSONAL HISTORY STATEIU ENT
F|LE NR_
INSTRUCTIONS
1. Answer all questions completely; if question is not applicable write "NA".
Write "Unknown" only if you do not know the answer and if the answer cannot be
derived from personal records, Use the blank pages at the back of this form for extra
details on any question for which you do not have sufficient space.
2. Type, print, or write carefully; illegible or incomplete forms will not receive
due consideration.
WARNING
1. The correctness of all statements of entries made herein may be
ascertained through investigation.
2. Any deliberate omission or distortion of information may give sufficient
cause for denial of clearance and unfavorable result of the investigation.
3, The statements made herein are classified CONFIDENTIAL. Revelation
or use other than the authorized purpose is prohibited by PhlP security policy.
t. TAILS
Name:
Rank:
Present Job/Assi
Business or Address:
Home Address (lnctude Street & No.)
Birth date: Bi
Change in Name (lf by Court Action, give deraits);
Nicknames: National
TIN:
SSS lD No.:
ID Phit No.
GSIS lD No.
Other Details:
[.
Sex:
hr: ht: meter
Build:
Fair Color of
Scars or and other distinguis h features:
Other
[!.
A. Marital Status
rafed or
Full Na
Date & Place of
B
and P Em
sig nature:
Date:
PNP Tmnsformalion:,,Our shared
commitment to deliver effilctive
and efficient police seryjces,:
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Other Details:
B. Children:
Name Date of Birth Citizenship and Address
Other Details
IV. FAMILY HISTORY AND INFORMATION
A Father:
Date of Birth
Place of Birth
Address:
Occupation and Place of Employment:
Citizenship (lf naturalized, give date and place where naturalized):
Other Details
B. [/other:
Date of Birth
Place of Birth:
Address:
Occupation and Place of Employment:
Citizenship {lf naturalized, oive date and place where naturalized):
Other Details:
C. Brothers and Sisters:
Name Aqe Address
Other Details:
V. EDUCATIONAL BACKGROUNB
Level Name of Location lnclusive Year Awards
School Date of Graduated Received
Attendance
Elementary
High School
College
Post Graduate
Other Schoolino
Eligibility (Career Service I RA 101O-Board or Bar (cE$/c$EE) and other similar
qualifi cations required:
Signature: Date:
PNP Transformalion: "Our shared commitmentto daliver effeclive and efrcienl poric€ seryice$",
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coilE!DENr!At
vt. OF
lnclusive Dates Addresses Name of at least two i2)
hbors
lltx. tT sINCE TI"IE
Fosition 0n$
VIII. FNP ATTTN
Titl* of Nature of Awards
Train Attendance T
IX. EMPLOYMENT
lnclusive Type of Name/Address of Employer Reason for
Dates E
Have you cver been disn:issed cr forced to resign from a position? YES* NO*
tf state the reasonls.
Signature: Date:
PNP lranoformatian; "Oursiared commrfinenl fo de,iver etrecLve and efficiGnl po,ice seryic€'s':
coNElpENr!At
ggNEISE NI!At
X. A. FOR POLICE COMMISSIONED OFFICERS ONLY
Source of Commission/ Please Year lndicate the Date and Number of
Entry to the Officers Check Appointment Order
Corp
Pl\,1A
PNPA
AFP Reserve
Lateral Technical
Lateral Line
SPO4 - INSP
NAPOLCOM
Others, please specify:
B. FOR POLIGE NON.COMMI$SIONED OFFICER & NON.UNIFORMED
PERSONNEL
Date Entered the PNP Appointment Order Number
XI. FOREIGN COUNTRIES VISITED
Date Country Visited Purpose of Visit
XII. GHARAGTERREFERENCE
A. Give five (5) character references (known three years or longer, who are not related to
you)
Name Address
B. List down three (3) neighbors at your plesent address:
XIII. PLEASE COPY IN OWN HANDWRITING
"Our London business is good, but Vienna and Berlin are quite. Mr. D. Lloyd has
gone to Switzerland. He will be staying at 1946 Zernatt St. for a week and will be going to
Turnie and Rome joining Police Su perintendent Perry
XIV, ORGANIZATION
List grganizati on or social groups which you have been a member of:
Organization Address Date of Membership & Position
Held
Signature: Date:
PNP Transformation: "Our sharad commit,fi],enl to deli^ftr etractiva and efrcienl porice sgryic€s,i
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XV. ADMINISTRATIVE/CIVILICRIMINAL OFFENSE DATA
OFFENSE COMMITTED AS TYPE CHARGE DISPOSITION
CHARGED (State whether (Exonerated, convicted,
admin/civil/criminal and pending)
date) (State penalty if convicted)
XVI. MISCELLANEOUS
A. Are you entirely dependent on your salary? YES_ NO* lf No, please state the other
source of income:
B. Have you filed a Statement of your Assets and Liabilities with any government agency:
YES NCI [f so what agency?
C. Have your latest income tax return? YES_ NO_ lf Yes, amount paid for the last
calendar year:
D. use or or tfY to what extent?
E" Languages or dialects:
F. Hobbies, sports and past time:
XVII. CERTIFICATION
I certify that the foregoing answer$ are true and corect to the
best of my knowledge and belief and I agree that any misstatement
or omission as to materialfact will constitute ground for immediate
denial of mv application for clearance.
Signed at: Date:
(?x2)
Photo
(Witness) (Witness)
THUMBIUARKS
Signature of Applicant Left Right
$ubscribe and sworn to before me this _ _ day of
At Philippines, affiant exhibited to me his/her residence certificate No.
issued on _at
Phillppines.
(Admi nistrative Offi cer/Notary Pu blic)
{Rank and Designation)
Signature: Date:
PNP Transformation: "Our shared commitment to daliver etreclive and efficienf porice se/vices'l
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PERSOHAL HI$TORY STATEMENT
FiLE NR*-
IN$TRUCTIONS
1. Answer all questions completely; if qu*stion is not applicable write "NA'.
Write "Unknown" Only if you do nst know the answ*r and if the answer cannot be
derived from personai records. Use the blank paEes at the back of this form for extra
details on any question for which you do not have sufficient space.
Z. Type, print, or write carefully; illegible or incornplete forms will not receive
due consideration.
WARNING
1. The conectness of all statements of entries made herein may be
ascertained through investigation.
Z. Any deliberate omission or distorlion of information may give sufficient
cause for denial of clearance and unfavsrable result of the investigation"
3. The statements made herein are classified CONFIDENTIAL. Revelation
or u$e other than the authorized purpo*e is prohibited by PNP security policy.
!. PER.SONAL SET AILS
Name
Rank:
Present JoblAssignment
Business ar Dutv Address:
l-lorne Address (lnclude Street & Na.i
Birth date
Change in Name (lf by Court Action, give details)
Nicknames: Nationality:
TIN 5SS lD No.
PAG-|BiG lD No": PhilHealth lD No.:
SSIS lD l{o. Other Details:
II. PERSOHAL CI{ARACTERISTICS
Sex: Age: Height: (meter)
W*iqht: iks) Bi;ild:
Complexion tDark, Fair, Light): Color of
Colar of Hair:
Scars or Marks and other distinguishing features:
Other Details:
II!. MARITAL HISTORY
A. hiarital Status (Sinsle, Itdarried, $eparated or Widowed):
of f,lame
Date & Place of i\ilarriaEe:
Birth date:
Birthp{ace:
and Place of
$ignature: Date:
PIVP lraflsformation: "Our $haftd camm,?nenl fo deriver efeclive and efficient porice se/vices'i
goNElgENIlAt
