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Department of the Interior and Local Government
with name tag
Philippine Public Safety College
Original Copy
PHILIPPINE NATIONAL POLICE ACADEMY
(Passport Size)
Camp General Mariano N Castañeda, Silang, Cavite 4129
[1.5’ x 2”]
Tel # (02) 396-4076/Tele Fax # (049) 545-5939)
1. SURNAME 2.GENDER :
Male
FIRST NAME Female
MIDDLE NAME
16. Have you ever been dismissed from any employment, forced to resign or otherwise disciplined as a result of administrative case,
or convicted of any violation of law, ordinance or regulations before any civil court and/or military tribunal? : YES NO
If YES, attach copy of decision:
17. Do you have any criminal, administrative, or civil case on file before any Prosecutor’s Office or Court of Justice or other
derogatory record(s)? YES NO
18. Do you have any parental obligation, or has sired a child or children? YES NO
I hereby declare under the penalties of perjury that this application has been accomplished in good faith, verified by me and
to the best of my knowledge and belief and is a true, correct and complete statement pursuant to the provisions of pertinent laws, rules
and regulations of the Republic of the Philippines. I also authorize the agency head or his/her representative to verify/validate the
contents stated herein.
_______________________________
(Signature of Applicant)
SUBSCRIBED AND SWORN TO before me this _______ day of ________ at _______________________________ affiant
exhibiting to me his/her community tax certificate number ________ issued on ______ at ___________________________________.
_______________________________
Administering Officer