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 CityWARNING:
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 First Name Middle Name Qualifier)
2. RANK: PO1 3. DESIGNATION: 4. DATE DESIGNATED:
5. UNIT/STATION ADDRESS:BENGUET POLICE PROVINCIAL OFFICE 6. TELEPHONE NUMBER:
7. HOME ADDRESS (House no. / Street / City / Province)
8. DATE OF BIRTH:MARCH 03,1978 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
16. WEIGHT (kg): 70
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
24. OCCUPATION: HOUSEWIFE 25. DEPENDENTS
NAME DATE OF BIRTH RELATIONSHIP ADDRESS
26. HOUSING DATA
[ ] OWN HOUSE & LOT [ / ] RENT HOUSE [ ] OCCUPYING GOVERNMENT QUARTERS
[ ] OWN HOUSE ONLY [ ] RENT ROOM [ ] OTHERS (Specify)______________________
_____________________________
Signature
PNP Badge No.: 190513 T.I.N. 263-554-656 PSMBFI Policy No. LATEST 2x2
COLORED PICTURE
II. APPOINTMENT DATA
27. EFFECTIVE DATE OF APPOINTMENT OF PREVIOUSRANK BY CSC
STATUS DATE
TEMPORARY; __________________________________ PERMANENT____________________________________
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 __________________________________ 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
YEAR YEAR [ ] AFP Regular [ ] AFP Reserve [ ] SPO4-PINSP Promotion ________ [ ] PMA_________ [ ] CIS [ ] INP [ ] NAPOLCOM [ ] Lateral Entry ________ [ ] 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 DATE LOCATION CONDUCTED BY
PNP SPECIAL COUNTER INSURGENCY OPERATION UNIT
TRAINING
ABRA PPO PRO-COR
FIELD TRAINING PROGRAM BANGUED
ABRA
PRO-COR PUBLIC SAFETY BASIC
RECRUITMENT COURSE CART’S BAGUIO CITY PPSC _____________________________ Signature
V. NAPOLCOM/CIVIL SERVICE/PRC ELEGIBILITIES
TITLE OF EXAM DATE TAKEN WHERE TAKEN RATING OBTAINED
CRIMINOLOGY BOARD EXAM SEP.23,2000 BAGUIO CITY 78.45
CSC FOR POLICE OFFICER EXAMINATION
JULY 16,2000 BAGUIO CITY 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) (Exonerated, etc., - Penalty)STATUS/DISPOSITION
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 if “YES”, give particulars
POSITION PLACE DATE
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
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 RIGHT THUMBMARK
SUBSCRIBED AND SWORN to before me this _____________ day of ___________________________
at _________________________________________________________________, Philippines.
__________________________________________
