Pds Odprm Form 96 1

PDS-ODPRM Form 96-1

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

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.

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

(Last Name

2. RANK: PO1

First Name

Middle Name

3. DESIGNATION:

4. DATE DESIGNATED:

5. UNIT/STATION ADDRESS:BENGUET POLICE PROVINCIAL OFFICE 7. HOME ADDRESS (House no.

/

Street

8. DATE OF BIRTH:MARCH 03,1978

Qualifier)

/

6. TELEPHONE NUMBER: City

Province)

/

9. PLACE OF BIRTH:BOKOD, BENGUET

10. SEX: MALE

11. CIVIL STATUS: SINGLE

12. RELIGION:ROMAN CATHOLIC

13. COLOR OF HAIR:BLACK/WHITE

14. COLOR OF EYES:BLACK

15. HEIGHT (cm): 1.65

17. BLOOD TYPE: O

18. BUILT: MEDIUM

19.COMPLEXION: FAIR

20. IDENTIFYING MARKS:

21. LANGUAGE/DIALECT: IBALOI,ILOCANO,TAGALOG,ENGLISH

22. ETHNIC GROUP: KARAO TRIBE

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

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

25. DEPENDENTS DATE OF BIRTH RELATIONSHIP

[ / ] RENT HOUSE [ ] RENT ROOM

16. WEIGHT

(kg):

70

24. OCCUPATION: HOUSEWIFE ADDRESS

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

_____________________________ Signature 1

II. APPOINTMENT DATA 27. EFFECTIVE DATE OF APPOINTMENT OF PREVIOUS RANK BY CSC STATUS DATE TEMPORARY; __________________________________

28. EFFECTIVE DATE OF PROMOTION OF PREVIOUS RANK PER PNP SO/GO STATUS DATE TEMPORARY __________________________________

PERMANENT____________________________________ 29. EFFECTIVE DATE OF APPOINTMENT OF PRESENT RANK BY CSC STATUS DATE TEMPORARY ___________________________________

PERMANENT ___________________________________ 30. EFFECTIVE DATE OF PROMOTION OF PRESENT RANK PER PNP SO/GO STATUS TEMPORARY __________________________________

PERMANENT ___________________________________

PERMANENT __________________________________

31. IF PRESENT RANK PASSED TEMPORARY, STATE REASON: [ ] ELEGIBILITY [ ] TIG [ ] TRAINING [ ] OTHERS______________

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 ________

[ ] NAPOLCOM

[ ] Lateral Entry ________

YEAR [ ] PMA_________ [ ] PNPA _______

III. EDUCATIONAL BACKGROUND LEVEL

NAME OF SCHOOL

LOCATION

DATE

DEGREEEARNED/ UNITS

ELEMENTARY SECONDARY COLLEGE POST GRADUATE

IV. POLICE/MILITARY TRAINING/SEMINARS/CAREER COURSES COURSE TAKEN PNP SPECIAL COUNTER INSURGENCY OPERATION UNIT TRAINING FIELD TRAINING PROGRAM

DATE

PUBLIC SAFETY BASIC RECRUITMENT COURSE

LOCATION ABRA PPO

CONDUCTED BY PRO-COR

BANGUED ABRA CART’S BAGUIO CITY

PRO-COR PPSC

_____________________________ Signature

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V. NAPOLCOM/CIVIL SERVICE/PRC ELEGIBILITIES TITLE OF EXAM

DATE TAKEN

WHERE TAKEN

RATING OBTAINED

CRIMINOLOGY BOARD EXAM CSC FOR POLICE OFFICER EXAMINATION

SEP.23,2000 JULY 16,2000

BAGUIO CITY BAGUIO CITY

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

_____________________________

3

Signature

XII. PHYSICAL AND MEDICAL RECORDS DATE OF LAST MEDICAL EXAMINATION: MAY 2008

WHERE TAKEN:CAMP BADO DANGWA LA TRINIDAD BENGUET

DATE OF LAST DENTAL EXAMINATION: MAY 2008

WHERE TAKEN:CAMP BADO DANGWA LA TRINIDAD BENGUET

DATE OF LAST NP EXAMINATION: MAY 2008

WHERE TAKEN:CAMP BADO DANGWA LA TRINIDAD BENGUET

DATE OF LAST DRUG TEST: MAY 2008

WHERE TAKEN:CAMP BADO DANGWA LA TRINIDAD BENGUET

DATE OF LAST PFT:APRIL 24, 2012

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

_____________________________

4

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

5

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

RIGHT THUMBMARK

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

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