CONFIDENTIAL
Leave it blank
PERSONAL HISTORY STATEMENT
FILE 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 the 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 will be ascertained through
investigation.
2. Any deliberate omission or distortion of information will give sufficient cause for denial of
clearance and unfavorable result of the investigation.
3. The statement made herein are classified CONFIDENTIAL. Revelation or use other than the
authorized purpose is prohibited by PNP security policy.
Applicant’s personal
information
I. PERSONAL DETAILS
Name:
Rank:
Present Job/Assignment:
Business or Duty Address:
Home Address (Include Street No., Brgy and Municipality):
Provincial Address (Include Street No., Brgy and Municipality):
Birth Date: Birth Place:
Change in Name (if by Court Action, Give details) :
Nicknames: Nationality:
TIN: SSS ID NO. :
PAGIBIG ID No. : Phil Health ID No. :
GSIS ID No. : Other Detail :
II. PERSONAL CHARACTERISTIC
Sex: Age: Height: (meter)
Weight: (Kg) Build:
Complexion (Dark, Fair, Light) : Color of Eyes:
Color of hair:
Scars or Marks and other distinguishing features:
Other Details:
Signature of
Date of application
applicant
Signature: ___________________________ Date: ___________________________________
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III. MARITAL HISTORY
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information
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Marital Status (Single, Married, Separated or Widowed) :
Name of Spouse (Full Name) :
Date & Place of Marriage :
Birth Date :
Birth Place :
Occupation and Place of Employment :
Other Details :
Children :
Name Date of Birth Citizenship and Address
Others Details:
IV. FAMILY HISTORY & INFORMATION
A. Father (Full Name) :
Date of Birth :
Place of Birth :
Address :
Occupation and Place of Employment :
Citizenship (If naturalized, give the date and place where naturalized) :
Others Details :
B. Mother (Full Name) :
Date of Birth :
Place of Birth :
Address :
Occupation and Place of Employment :
Citizenship (If naturalized, give the date and place where naturalized) :
Others Details :
C. Brothers and Sisters :
Name Age Address Occupation
Others Details : Signature of
Date of application
applicant
Signature: _________________________________ Date: _____________________
V. EDUCATIONAL BACKGROUND
Level Name of School Location Inclusive Date Year Awards
of Attendance Graduated Received
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information
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Elementary
Secondary
College
Post Graduate
List all Eligibilities
Other Schooling
Eligibilities (Career Service/RA1080-Board or Bar/CES/CSEE) and other similar qualifications required
VI. PLACE OF RESIDENCE SINCE BIRTH
Inclusive Addresses Name of at least two (2) Neighbors
Dates
VII. UNIT ASSIGNMENT SINCE ENTERED THE PNP
Position Date Unit Qualifications
Trainings/ Schoolings, Seminar
needed for the position
VIII. PNP TRAININGS/SEMINARS ATTENDED
Tittle of Date of Nature of Conducted by Awards Received
Training/Seminars Attendance Training
Signature of
Date of application
applicant
Signature: _________________________________ Date: _____________________
IX. EMPLOYMENT
Inclusive Date Type of Name/Address of Employer Reason of
Employment Leaving
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DATE- PRESENT Permanent PNP-Unit/ Address Active
Have you ever been dismissed or forced to resign from a position< YES_____ NO_____
If yes, State the reason/s. FOR PCO
X. A. FOR POLICE COMMISIONED OFFICER ONLY
Source of Commission/ Please Year Indicate the Date and Number of Appointment Order
entry to the Officers Check
/Corp
PMA
PNPA
AFP Reserve
Lateral Technical
Lateral Line
SPO4 - INSP
NAPOLCOM
FOR PNCO
Other, Please Specify:
B. FOR POLICE NON-COMMISSIONED OFFICER & NON-UNIFORMED PERSONNEL
Date Entered the PNP Appointment Order
XI. FOREIGN COUNTRY VISITED
Date Country Visited Purpose of Visit
XII. CHARATER REFERENCE
Give five (5) character references (known three years or longer, who are not related to you).
Name Address and Telephone Number
Signature of
Date of application
applicant
Signature: _________________________________ Date: _____________________
B. List down three (3) neighbors at your present address:
Name Address and Telephone Number
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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
Superintendent Perry. Hand Written
XIV. ORGANIZATION
List of organization or social groups which you have been a member of:
Organization Address Date of Membership & Position Held
XV. ADMINISTRATIVE/CRIMINAL OFFENSE DATA
OFFENSE COMMITED AS TYPE CHARGE DISPOSITION
CHARGED (State whether (Exonerated, convicted, pending)
admin/civil/criminal and date) (State penalty if convicted)
XVI. MISCELLANEOUS
If yes, indicate the YES or NO
A. Are you entirely dependent on your salary? YES_____ NO_____ If No, please state other source of
Amount of taxes
income:
withheld in the last ITR
B. Have you filed a Statement of your Assets and Liabilities with any government agency?
C. Have you filed your latest income tax return? YES______ No______ If Yes, amount paid for the last
calendar year:
D. Do you intoxicating liquor or narcotics? YES______ No______ If Yes, to what extent?
E. Languages or dialects:
F. Hobbies, sports and past time:
Signature of Date of application
applicant
Signature: _________________________________ Date: _____________________
XVII. CERTIFICATION
Attach latest 2x2 picture
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I certify that the foregoing answers are true and correct to the best of
my knowledge and belief and I agree that any misstatement or omission as
to material fact will constitute ground for immediate denial of my application
for clearance.
Signed at: Date:
Name and signature Name and signature
Personally known by applicant Personally known by applicant (2X2)
for 3 years for 3 years Photo
(Witness) (Witness)
Affix thumbmark
Signature of applicant THUMBMARKS
_____________________________________
Signature of Applicant
Left Right
Cedula or PNP ID
Subscribe and sworn to before me this ________ day of _____________________ 20__ at
___________________________, Philippines, affiant exhibited to me his/her PNP ID no.
___________________________ issued on _______________________20__ at
___________________________, Philippines.
Chief Admin or any
PCO
______________________________________
(Administrative Officer/Notary Public)
__________________________________
(Rank and Designation)
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