PDS-ODPRM Form 96-1

NATIONAL HEADQUARTERS PHILIPPINE NATIONAL POLICE

Camp Crame, Quezon City PNP Badge No.: 190513 T.I.N. 263-554-656 LATEST 2x2 COLORED PICTURE PSMBFI Policy No.

Republic of The Philiippines Department of the Interior and Local Government NATIONAL POLICE COMMISSION

WARNING:

The correctness of all statements or entries made herein in is subject to verification and any deliberate correction and distortion of information may give sufficient cause for Investigation.

Date Accomplished:_____________________________ I. GENERAL INFORMATION

1. NAME 2. RANK: PO1 (Last Name First Name 3. DESIGNATION: Middle Name Qualifier)

4. DATE DESIGNATED: 6. TELEPHONE NUMBER:

City / Province)

5. UNIT/STATION ADDRESS:BENGUET POLICE PROVINCIAL OFFICE 7. HOME ADDRESS (House no. 8. DATE OF BIRTH:MARCH 03,1978 10. SEX: MALE 13. COLOR OF HAIR:BLACK/WHITE 17. BLOOD TYPE: O 20. IDENTIFYING MARKS:
/ Street /

9. PLACE OF BIRTH:BOKOD, BENGUET 12. RELIGION:ROMAN CATHOLIC 15. HEIGHT (cm): 1.65 16. WEIGHT
70 (kg):

11. CIVIL STATUS: SINGLE 14. COLOR OF EYES:BLACK 18. BUILT: MEDIUM 21. LANGUAGE/DIALECT: IBALOI,ILOCANO,TAGALOG,ENGLISH

19.COMPLEXION: FAIR 22. ETHNIC GROUP: KARAO TRIBE 24. OCCUPATION: HOUSEWIFE ADDRESS

23. NAME OF SPOUSE OR NEAREST KIN/ADDRESS: LYDIA D. PINOSAN #96 HONEYMOON RD. BAGUIO CITY NAME 25. DEPENDENTS DATE OF BIRTH RELATIONSHIP

26. HOUSING DATA [ ] OWN HOUSE & LOT [ ] OWN HOUSE ONLY

[ / ] RENT HOUSE [ ] RENT ROOM

[ ] OCCUPYING GOVERNMENT QUARTERS [ ] OTHERS (Specify)______________________

_____________________________ Signature 1

II. APPOINTMENT DATA

27. EFFECTIVE DATE OF APPOINTMENT OF PREVIOUS RANK BY CSC STATUS DATE TEMPORARY; __________________________________ PERMANENT____________________________________ 29. EFFECTIVE DATE OF APPOINTMENT OF PRESENT RANK BY CSC STATUS DATE TEMPORARY ___________________________________ PERMANENT ___________________________________ 31. IF PRESENT RANK PASSED TEMPORARY, STATE REASON: [ ] ELEGIBILITY [ ] TIG [ ] TRAINING [ ] OTHERS______________ 28. EFFECTIVE DATE OF PROMOTION OF PREVIOUS RANK PER PNP SO/GO STATUS DATE TEMPORARY __________________________________ PERMANENT ___________________________________ 30. EFFECTIVE DATE OF PROMOTION OF PRESENT RANK PER PNP SO/GO STATUS TEMPORARY __________________________________ PERMANENT __________________________________ 32. DATE SATISFIED THE DEFICIENCY: DEFICIENCY: ____________________________(specify) MONTH/YEAR: _________________________

FOR POLICE COMMISSIONED OFFICERS ONLY

SOURCE OF COMMISSION/ENTRY TO THE PNP [ ] AFP Regular [ ] CIS [ ] AFP Reserve [ ] INP YEAR [ ] SPO4-PINSP Promotion ________ [ ] Lateral Entry ________ YEAR [ ] PMA_________ [ ] PNPA _______

[ ] NAPOLCOM

III. EDUCATIONAL BACKGROUND

LEVEL ELEMENTARY SECONDARY COLLEGE POST GRADUATE NAME OF SCHOOL LOCATION DATE DEGREEEARNED/ UNITS

IV. POLICE/MILITARY TRAINING/SEMINARS/CAREER COURSES

COURSE TAKEN PNP SPECIAL COUNTER INSURGENCY OPERATION UNIT TRAINING FIELD TRAINING PROGRAM PUBLIC SAFETY BASIC RECRUITMENT COURSE DATE LOCATION ABRA PPO BANGUED ABRA CARTS BAGUIO CITY CONDUCTED BY PRO-COR PRO-COR PPSC

_____________________________ Signature

V. NAPOLCOM/CIVIL SERVICE/PRC ELEGIBILITIES

TITLE OF EXAM CRIMINOLOGY BOARD EXAM CSC FOR POLICE OFFICER EXAMINATION DATE TAKEN SEP.23,2000 JULY 16,2000 WHERE TAKEN BAGUIO CITY BAGUIO CITY RATING OBTAINED 78.45 80.61

VI. PERFORMANCE EVALUATION RATING (Immediately preceding two (2) semesters)

RATING PERIOD RATING RATER

VII. PHYSICAL FITNESS TEST RATING (Immediately preceding two (2) semesters)
FITNESS PERIOD RATING CONDUCTED BY

VIII. STATEMENT OF ASSETS AND LIABILITIES, NETWORTH (Immediately receding three (3) Fiscal Years)

THIS WILL BE COMPARED TO THE SUBMITTED SALNs AND VERIFIED BY RMD, DPRM
FISCAL YEAR TOTAL ASSETS TOTAL LIABILITIES NET WORTH

IX. INDIVIDUAL INCOME TAX RECORDS (Immediately preceding three (3) Fiscal Years)
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 of 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 reasons other than lack of funds? [ ] YES [ ] NO if YES, give particulars

Have you ever been a candidate in a national or local election (including Barangay election)? [ ] YES [ ] NO POSITION if YES, give particulars PLACE DATE

_____________________________

Signature

XII. PHYSICAL AND MEDICAL RECORDS

DATE OF LAST MEDICAL EXAMINATION: MAY 2008 DATE OF LAST DENTAL EXAMINATION: MAY 2008 DATE OF LAST NP EXAMINATION: MAY 2008 DATE OF LAST DRUG TEST: MAY 2008 DATE OF LAST PFT:APRIL 24, 2012 WHERE TAKEN:CAMP BADO DANGWA LA TRINIDAD BENGUET WHERE TAKEN:CAMP BADO DANGWA LA TRINIDAD BENGUET WHERE TAKEN:CAMP BADO DANGWA LA TRINIDAD BENGUET WHERE TAKEN:CAMP BADO DANGWA LA TRINIDAD BENGUET WHERE TAKEN:BENGUET PPO

XIII. POLICE/MILITARY MAJOR DESIGNATIONS (FOR PCOs: AS PLTN LEADER, COP, BN/CPS/CPO,PPO,PRO,NSU STAFF, MG COMDR, CD/PD)
POSITION/DESIGNATION UNIT/OFFICE INCLUSIVE DATE

XIV. PROMOTION RECORDS

OLD RANK NEW RANK EFFECTIVITY DATE PROMOTION STATUS AUTHORITY

XV. OTHER COURSES/TRAININGS/SEMINARS (IN PRESENT RANK)

COURSE TAKEN DATE TRAINING HOURS SCHOOL LOCATION HONORS RECEIVED

_____________________________

Signature

XVI. FIREARMS RECORD

MR/LIC NO. KIND MAKE CALIBER AMMO ISSUING UNIT

XVII. AWARDS AND RECOGNITIONS RECEIVED (IN PRESENT RANK) INDIVIDUAL MEDALS/RIBBONS
NATURE OF AWARD DATE AWARDED AUTHORITY

INDIVIDUAL AND UNIT CITATION BADGE

INDIVIDUAL AND UNIT AWARDS/STREAMERS

LETTERS OF COMMENDATIONS/PLAQUES/CERTIFICATE OF APPRECIATION/COMMENDATION/MERITS (NOT YET CONVERTED TO PNP MEDALS)

ACADEMIC AWARDS
NATURE OF AWARD DATE INSTITUTION

_____________________________ 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 dishonestly as a result of any false misrepresentation or omission in this Personal Data Sheet.

__________________________________________

Community Tax Certificate No. __________________ Issued on __________________________________ Issued at ___________________________________

LEFT THUMBMARK

RIGHT

SUBSCRIBED AND SWORN to before me this _____________ day of ___________________________ at _________________________________________________________________, Philippines.

__________________________________________

Chief, Regional Legal Service NHQ/NSU/PRO Official Seal

*Not valid without Notarial Seal