Republic of the Philippines

National Police Commission

PHILIPPINE NATIONAL POLICE
POLICE SECURITY AND PROTECTION GROUP
Protection and Escort Division
Camp BGen Rafael T Crame, Quezon City

Series of 2010
DATE FILED : _________________ REFERENCE NO:__________________
RECEIVED BY : _________________

APPLICATION FOR AVAILMENT OF PROTECTIVE SECURITY PERSONNEL

(Note: Please accomplish/file three (3) copies)

1. NAME OF APPLICANT : ________________________________________________

Cabinet Secretary

Department
Member of the Senate
Position/Committee Chairmanship/Member: __________________________________________________

Member of the House of Representative District:________________ City/Province:__________________

Position/Committee Chairmanship/Member):
____________________________________________________________________________________

Retired PNP/AFP Star-Rank Officer Date of Retirement : _______________________________________

2. COMPLETE MAILING ADDRESS/COMPLETE HOME ADDRESS:

___________________________________________________________________________________________

___________________________________________________________________________________________

3. BIRTHDATE: _________________ 4. AGE: _________ 5. SEX: ________ 6. CITIZENSHIP: ________________

7. CIVIL STATUS: ____________________8. NAME OF SPOUSE: _______________________________________

9. OFFICE TELEPHONE NO.: _________________ 10. CELLPHONE NO.: ________________________________

11. E-MAIL ADDRESS.: ____________________________

_________________________________________________________________________________________________

CERTIFICATION
I HEREBY CERTIFY THAT THE FOREGOING ARE TRUE AND CORRECT BASED ON MY PERSONAL
KNOWLEDGE AND BELIEF. I UNDERSTAND THAT ANY MISREPRESENTATION HEREIN WILL BE A GROUND FOR
THE DENIAL OF MY APPLICATION.

2X2
Recent I.D.
_____________________________________
Picture
Signature above printed name

SUBSCRIBED AND SWORN to before me this ____ day of __________________, 2018 at ________________
__________________________________________________________, Philippines.

Doc. No. : ___________

Page No : . ___________ NOTARY PUBLIC
Book No : ______._____
Series of 2018.