APPLICATION FOR BI ACCREDITATION ID

PERSONAL DATA SHEET (PDS)

I. PERSONAL INFORMATION
SURNAME FIRST NAME MIDDLE NAME DATE OF BIRTH (mm/dd/yyyy) PLACE OF BIRTH SEX CIVIL STATUS NAME EXTENSION (e.g. Jr., Sr.)

RESIDENTIAL ADDRESS

Male Single Married Annulled

Female Widowed Separated Others, specify______

PERMANENT ADDRESS
ZIP CODE TELEPHONE NO.

CITIZENSHIP HEIGHT (m) WEIGHT (kg) BLOOD TYPE GSIS ID NO. PAG-IBIG ID NO. PHILHEALTH NO. SSS NO.

ZIP CODE TELEPHONE NO. E-MAIL ADDRESS (if any) CELLPHONE NO. (if any) AGENCY EMPLOYEE NO. TIN

II. FAMILY BACKGROUND

SPOUSE'S SURNAME FIRST NAME MIDDLE NAME OCCUPATION EMPLOYER/BUS. NAME BUSINESS ADDRESS TELEPHONE NO. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

/ / / / / /

/ / / / / /

(Continue on separate sheet if necessary)

FATHER'S SURNAME FIRST NAME MIDDLE NAME MOTHER'S MAIDEN NAME SURNAME FIRST NAME MIDDLE NAME

/ / / / / /

/ / / / / /

III. WORK EXPERIENCE (Include private and government employment. Start from your current work)
INCLUSIVE DATES (mm/dd/yyyy) From To POSITION TITLE (Write in full) DEPARTMENT / AGENCY / OFFICE / COMPANY (Write in full)
STATUS OF APPOINTME NT

INCLUSIVE DATES

(Continue on separate sheet if necessary)

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IV. TRAINING PROGRAMS (Start from the most recent training.)

TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write in full) INCLUSIVE DATES OF ATTENDANCE From (mm/dd/yyyy) To NUMBER OF HOURS CONDUCTED/ SPONSORED BY (Write in full)

V. OTHER INFORMATION
SPECIAL SKILLS / HOBBIES: MEMBERSHIP IN NON-ACADEMIC DISTINCTIONS / RECOGNITION: ASSOCIATION/ORGANIZATION (Write in full) (Write in full)

VI. RELATIVES WITHIN THE BUREAU OF IMMIGRATION (FOURTH DEGREE OF CONSAGUINITY OR AFFINITY)
NAME POSITION DIVISION

a. Have you ever been administratively or criminally charged in court? b. Have you ever been guilty of any administrative offense? Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal?

Have you ever been separated from employment in any of the following modes: resignation, retirement, dropped from the rolls, dismissal, termination, end of term, finished contract, AWOL or phased out, in the public or private sector? REFERENCES (Person not related to any Bureau of Immigration personnel)
NAME ADDRESS

YES NO If YES, give details: ________________________________ YES NO ________________________________ If YES, give details: ________________________________ YES NO ________________________________ If YES, give details: ________________________________ ________________________________ YESgive details: NO If YES, ________________________________ ________________________________
TEL. NO.
ID picture taken within the last 6 months 3.5 cm. X 4.5 cm (passport size) Computer generated or xerox copy of picture is not acceptable

I declare under oath that this Personal Data Sheet has been accomplished by me, 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 / authorized representative to verify / validate the contents stated herein. I trust that this information shall remain confidential.

PHOTO

COMMUNITY TAX CERTIFICATE NO.

ISSUED AT

SIGNATURE (Sign inside the box)

ISSUED ON (mm/dd/yyyy)

DATE ACCOMPLISHED

RIGHT THUMBMARK

REPUBLIC OF THE PHILIPPINES CITY OF MANILA, SUBSCRIBED AND SWORN to before me this _____ day of ________________, 201___ at the City of Manila, Philippines. ATTY. FELINO C. QUIRANTE, JR. Chief, Administrative Division
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