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