PS Application Form B-2019

APPLICATION FOR AVAILMENT OF PROTECTIVE SECURITY

(Please fill out form completely and legibly)

1. COMPLETE NAME
Surname:

First Name: Qualifier:

Middle Name:

2. POSITION IN GOVERNMENT (Please check appropriate box below):

Head of National Government Agency/Bureau
Undersecretary or equivalent rank
Assistant Secretary or equivalent rank
Trial Court Judge
State Prosecutor

3. COMPLETE MAILING ADDRESS:

House/Unit/Room/Building Number and Street:

Village/Subdivision:

Barangay:

City/Municipality:

Province:

4. CONTACT NO.:

5. E-MAIL ADDRESS:

6. JUSTIFICATION FOR AVAILMENT OF PROTECTIVE SECURITY:

________________________________________________________________________________________
(Please attach official police report/blotter issued by the Chief of Office or authorized PCO-representative to support application)

2x2 ID Photo

(computer-
generated photo
is not valid)
CERTIFICATION
I HEREBY CERTIFY THAT THE FOREGOING ARE TRUE AND CORRECT BASED ON MY PERSONAL
KNOWLEDGE AND BELIEF.

_______________________________
Applicant’s signature over printed name
SUBSCRIBED AND SWORN to before me this _____ day of _____________________________, 2019 at
_________________________________________, _______________________________________, Philippines.

Doc. No.______
Page No._____ NOTARY PUBLIC
Book No._____
Series of 2019