Republic of the Philippines)

)
) . . .s.s.

AFFIDAVIT OF CONFIRMATION

I, ______________________________________, a Filipino of legal age, a

resident of ___________________________________, a bona fide member of the
Philippine National Police with the rank of _____________ and presently assigned at
______________ after having been duly sworn to in accordance with law, do hereby
depose and says that:

1. Pursuant to this affidavit, I am confirming that the following are my legal

beneficiaries and/or heirs, to wit:

NAME RELATIONSHIP BIRTHDATE

___________________________ _____________ __________

___________________________ _____________ __________
___________________________ _____________ __________
___________________________ _____________ __________
___________________________ _____________ __________

2. My relationship with persons whose names are listed above are borne out
by the fact that I am the lawful spouse and the legitimate/illegitimate
father/mother of the afore-named children as evidenced by the attached
marriage contract and birth certificates:

3. I hold myself criminally and administratively liable for perjury and dishonesty
should any statements made herein are inaccurate or later on found to be
false and in of law.

AFFIANT SAYETH NAUGHT:

_________________________
Affiant

SUBSCRIBE AND SWORN to before me this ____ day of _____________ at

________________________ Philippines.

Doc No. _________

Page No. _________
Book No. _________
Series No. _________
DPRM RSD FORM 2015-01-C
Republic of the Philippines
National Police Commission
NATIONAL HEADQUARTERS, PHILIPPINE NATIONAL POLICE
Camp Crame, Quezon City

AFFIDAVIT OF UNDERTAKING

I, ____________________________________________________, of legal age,

Filipino, (First Name) (Middle Name) (Last Name) (Qualifier)

presently residing at _________________________________________________after

having, been duly sworn to in accordance with law, do hereby depose and state that:

1. I am an applicant for this CY_______Pat/Lateral Entry Program (Line/Technical

Officers) recruitment program;

2. I am a graduate of _________________________________________________
(Degree/Course)
and holder of _________________________________________ eligibility;

3. I was born on ____________________ (Month/Day/Year format) as appearing in

my ______________________(Proof of Birth e.g. NSO issued Birth
Certificate/Local Registry Birth Certificate), and that I am hereby notified that my
declared birth date indicated herein shall become incontestable in so far as my
service in the PNP is concerned after the lapse of six (6) months from the effectivity
of my appointment;

4. That in the event that I will file a petition to alter or correct entries in my birth
records before any court or the CSC, I hereby undertake to first inform the DPRM
(Attn: C, RMD) before filing the same; and

5. That I am aware that any misrepresentation, omission, or misdeclaration of my

birth date committed during the initial recruitment/appointment process, or finding
that I entered the service below the minimum or above the maximum allowable age
at the time of my appointment, without the necessary age waiver shall be a ground
for the filing of an administrative case/institution of termination proceedings for
dishonesty, as applicable, as well as the filing of criminal charges for perjury.

_____________________________
Affiant

SUBSCRIBED AND SWORN TO before me this ____ day of _______________,

20___, at ____________________________, Philippines.

________________________
(Notary Public)

Doc:________
Page:_______
Book:________
Series of ______
COMPLETE BACKGROUND INVESTIGATION (CBI)
I. PERSONAL DATA
NAME DATE OF BIRTH CIVIL BLOOD WEIGHT ETHNIC
(mm//dd/yy) PLACE OF BIRTH SEX AGE ADDRESS RELIGION BUILD COMPLEXION
(Last Name, First Name, Middle Initial) STATUS TYPE (KG) GROUP

II. EDUCATIONAL BACKGROUND

YEAR AWARDS
SCHOOL LOCATION DATE OF ATTENDANCE GRADUATED RECEIVED PLACE OF RESIDENCE

III. PLACES OF RESIDENCE SINCE BIRTH

INCLUSIVE DATE ADDRESS (include number of street and barangay)

Page 1 of 4
1CY2023_2023_Y360T4
IV. EMPLOYMENT RECORDS
TYPE/NATURE OF INCLUSIVE DATES & NO. REASON FOR
AGENCY/COMPANY ADDRESS EMPLOYMENT OF YEARS OF SERVICE LEAVING PLACE OF RESIDENCE

IV. IF MARRIED
DATE OF BIRTH DATE OF
NAME OF SPOUSE (mm//dd/yy)
PLACE OF BIRTH ADDRESS NATIONALITY
MARRIAGE
PROFESSION/OCCUPATION

SON/DAUGHTER DATE OF BIRTH PLACE OF BIRTH PLACE OF RESIDENCE

NAME OF CHILDREN (mm//dd/yy)

V. FAMILY HISTORY
DATE OF BIRTH
NAME OF FATHER (mm//dd/yy)
PLACE OF BIRTH AGE ADDRESS OCCUPATION OFFICE BUSINESS

Page 2 of 4
1CY2023_2023_Y360T4
 DATE OF BIRTH
NAME OF MOTHER (mm//dd/yy)
PLACE OF BIRTH AGE ADDRESS OCCUPATION OFFICE BUSINESS

NAME OF BROTHER/S AND DATE OF BIRTH

(mm//dd/yy)
PLACE OF BIRTH AGE ADDRESS OCCUPATION OFFICE BUSINESS
SISTER/S

*Use the back sheet if necessary

VI. CHARACTER REFERENCES
NAME ADDRESS CONTACT NUMBER OCCUPATION

VII. NEIGHBORHOOD INVESTIGSTION

NAME ADDRESS CONTACT NUMBER OCCUPATION

Page 3 of 4
1CY2023_2023_Y360T4
VIII. Draw the Sketch of your address/residence

Page 4 of 4
1CY2023_2023_Y360T4
 1CY2023_2023_Y360T4
PNP HS FORM NO. 2014-04

Republic of the Philippines 2x2 colored picture with white

NATIONAL POLICE COMMISSION background and the name should
PHILIPPINE NATIONAL POLICE appear below the picture
HEALTH SERVICE (LAST, FIRST, M.I. & BELOW IS THE
Camp Rafael T Crame, Quezon City RANK).

FINAL PHYSICAL MEDICAL-DENTAL EXAMINATION REPORT

CONTROL NO.
RANK LAST NAME FIRST NAME MIDDLE NAME AGE/SEX CIVIL STATUS
RONES JASON VILLANUEVA
UNIT ASSIGNMENT/ADDRESS CONTACT NUMBER

POSITION BADGE NO. DATE OF BIRTH PLACE OF BIRTH RELIGION

LENGTH OF SERVICE PERMANENT HOME ADDRESS (NUMBER, STREET, CITY OR TOWN PROVINCE)

NEXT OF KIN (Name, Relationship, Address, Contact No.)

DATE OF EXAMINATION PURPOSE OF EXAMINATION REQUESTING AUTHORITY

THIS PART IS TO BE FILLED UP BY MEDICAL STAFF/ MEDICAL OFFICER

COLOR OF HAIR COLOR OF EYES BLOOD TYPE IDENTIFYING MARKS (birthmarks, scars, mole, tattoo, etc)

HEIGHT (cm) WEIGHT (kg) WAISTLINE (in) BP (mmHg) CAR (bpm) RR (cpm) TEMP (Co)

BMI (wt in kg / FOR FEMALES: CXR (result) VISUAL ACUITY

ht in m2): ( ) UNDERWEIGHT < 18.5
OBSTETRIC SCORE G ___P ___ ( __ __ __ __ ) OD
( ) NORMAL 18.5-22.9
LMP ___________________ ECG (result) OS
( ) OVERWEIGHT 23-24.9 OU
( ) OBESE I 25-29.9  NSD  C/S ____x  ABORTION
HBsAg (result)
( ) OBESE II > 30 Color Vision

PERTINENT PHYSICAL EXAMINATION FINDINGS: FINAL DENTAL EXAMINATION FINDINGS:

DENTAL REMARKS:

AUTHORIZED DISPOSITION
EXAMINATION DATE REMARKS
SIGNATURE GRANTED NOT GRANTED
GENERAL MEDICAL EXAMINATION

NEURO-PSYCHIATRIC EXAM

DENTAL EXAMINATION

FINAL DISPOSITION
PHYSICAL HEALTH PROFILE
 RECOMMENDED (Encircle)
 NOT RECOMMENDED (State reason thereof): P1 P3
P2 P4

DATE: _______________________

____________________________________________________________
SIGNATURE OVER PRINTED NAME
C, MEDICAL-DENTAL BOARD
Identification QR Code
 1CY2023_2023_Y360T4
PNP HS MS FORM NO. 2014-01
2x2 colored picture with white
background and the name should
Republic of the Philippines appear below the picture
National Police Commission (LAST, FIRST, M.I.)
PHILIPPINE NATIONAL POLICE
HEALTH SERVICE
Camp PBGen Rafael T Crame, Quezon City
PICTURE SHOULD BE
WITHOUT HEADGEAR,
MOUSTACHE, EYE GLASSES OR
MEDICAL HISTORY REPORT SUN GLASSES.

Medical Prescreen Questionnaire

DATE: _______________________ CONTROL NO.

RANK LAST NAME FIRST NAME MIDDLE NAME AGE SEX CIVIL STATUS
RONES JASON VILLANUEVA

PERMANENT HOME ADDRESS (NUMBER,STREET,CITY OR TOWN PROVINCE) CONTACT NUMBER

DATE OF BIRTH PLACE OF BIRTH RELIGION PURPOSE OF EXAMINATION

NEXT OF KIN (NAME, RELATIONSHIP, ADDRESS, CONTACT NO.)

INSTRUCTION: The instructions contained hereto and in the other medical forms are pertinent and vital. They shall be part of the personnel’s medical records. The
information you will give shall constitute an official statement. They are to be filled-up properly, honestly and with outmost integrity. If you are
accepted into the PNP based on a false statement herein you can be recommended for summary dismissal proceedings in the future.
PLEASE CHECK AND WRITE YOUR ANSWERS ON THIS QUESTINNAIRE ON THE SPACE PROVIDED may use additional sheet/s if necessary.
STATE OF HEALTH
Stable w/
1. FAMILY MEMBERS NAME DATE OF BIRTH known Serious If deceased
Good please indicate
medical ly ill cause of death
condition/s

a. FATHER’S NAME

b. MOTHER’S NAME

c. SIBLINGS

d. SPOUSE’S NAME

e. CHILDREN’S NAME

2. FAMILY MEDICAL HISTORY

a. Have anyone in your family suffered from the following:
CONDITIONS YES NO RELATIONSHIP CONDITIONS YES NO RELATIONSHIP
Diabetes Hepatitis
Stroke Kidney Disease
Heart Disease Leukemia/Blood Cancers
High Blood Pressure Bleeding Disorders
Asthma Mental Disorder
Pulmonary Tuberculosis Drinking Problem
Goiter/Thyroid Disease Smoking Problem

b. Do you have any family member who died of heart disease? ‫ ﭪ‬YES ‫ ﭪ‬NO If YES, indicate relationship and age at the time of
death______
Page 1 of 3
 1CY2023_2023_Y360T4
3. PERSONAL SOCIAL HISTORY 4. WOMEN’S HEALTH HISTORY

Describe YES NO No. of

Age at start of Menses:
Pregnancies
Smoking sticks ______per day since_________
No. of deliveries REGULAR ‫ ﭪ‬YES ‫ ﭪ‬NO
Stopped Smoking when__________________
No. of abortions DYSMENORRHEA ‫ ﭪ‬YES ‫ ﭪ‬NO
Alcohol ___________ x per month
No. of
Menses Interval Menses Duration
Stopped Drinking Alcohol when______________ miscarriages
Date of Last Mentrual
Prohibited Drugs _______ days _______ days
Period:
Exercise ______min/s per day ______x per month Last Pap Smear:
Right-handed ‫ ﭪ‬YES ‫ ﭪ‬NO
Normal:
Left-handed Current Method of Contraception, if there’s any:
Usual Physical Activities/Sports Played (how often)

5. VACCINATION HISTORY
Vaccine YES NO When No. of doses Vaccine YES NO When No. of doses
Hepatitis A Typhoid
Hepatitis B Varicella (Chicken pox)
Influenza (Flu) Tetanus
Pneumonia Measle, Mumps, Rubella
Others: Others:

6. MEDICATION HISTORY
a. Current Medications you are taking if there are any: b. Allergies to Medications, drugs or food, if there are any:

7. PAST MEDICAL HISTORY, HOSPITALIZATION & SURGERY: If YES, please describe in the separate portion)
Have you ever had or do you now have the following: YES NO Have you ever had or do you now have the following: YES NO
1. Asthma, wheezing, or inhaler use 35. Epilepsy, fits, seizures, or convulsions
2. Tuberculosis 36. Sleepwalking
3. Collapsed lung or other lung condition 37. Fainting spells or passing out
4. Pneumonia 38. Bed wetting at age 12
5. Whooping cough 39. Heat Exhaustion
6. Diptheria 40. Absence or disturbance of the sense of smell
7. Anemia 41. Recurrent nose bleeding
8. Rheumatic Fever 42. Detached retina or surgery for a detached retina
9. Malaria 43. Wear contact lenses
10. Chicken Pox 44. Night blindness
11. Typhoid Fever 45. Any other eye condition, injury or surgery
12. Measles 46. Double vision
13. Mumps 47. Perforated ear drum or tubes in ear drum/s
14. Passing out of worms (parasitic infections) 48. Recurrent ear infection
15. Ulcer 49. Frequent or severe headaches
16. Hepatitis A or B 50. Recurrent neck or back pain
17. Jaundice (yellow discoloration of the skin and eyes) 51. Arthritis or frequent joint pains
18. Anorexia or other eating disorders 52. Fracture in any part of the body
19. Intestinal obstruction (locked bowels) 53. Pain or swelling at the site of an old fracture
20. Gall bladder disease or gall stones 54. Swelling of joints
21. Kidney Disease, including kidney stones 55. Lower extremity weakness
22. Sexually-Transmitted Infections 56. Paralysis of any part of the body
23. Recurrent Urinary Tract Infections 57. Used any form of body support or braces
24. Missing a kidney 58. Donated blood
25. (Females only) Dysmenorrhea 59. Received blood transfusion
26. (Males only) Missing a testicle, testicular implant, 60. Eye surgery, including radial keratotomy, lens
or undescended testicle implant or other eye surgery to improve your vision
27. Goiter or thyroid disease or with thyroid 61. Ear surgery, to include repair of perforated ear
medications drum, hearing loss or need/use a hearing aid
28. High blood sugar (diabetes) or with diabetes 62. Head injury, including skull fracture, resulting in
medications concussion, loss of consciousness, headaches, etc.
Page 2 of 3
 1CY2023_2023_Y360T4
29. High blood pressure or with hypertension 63. Dislocated joint, including knee, hip, shoulder,
medications elbow, ankle or other joint
30. Irregular heartbeat, including abnormally rapid or 64. Broken bone requiring surgery to repair (w/ or w/o
slow heart rates pins, plates, screws or other metal fixation devices)
31. Heart murmur, valve problem or mitral valve 65. Surgery to remove a portion of the intestine (other
prolapse than the appendix)
32. Discharged from military service for medical 66. Any illnesses, surgery, or hospitalization not listed
reasons above
33. Been rejected for military service (temporary or 67. Evaluation, treatment, or hospitalization for
permanent) for medical or other reasons alcohol abuse, dependence, or addiction
34. Seen a psychiatrist, psychologist, social worker, 68. Evaluation, treatment, or hospitalization for
counselor or other professional for any reason substance use, abuse, addiction or dependence
(inpatient or outpatient) (including illegal drugs, prescription medications)
Describe in detail every YES answer, including how it was known, treatment done, etc.

8. REVIEW OF SYSTEMS
Have YOU had problems with any of the following within the past year?
GENERAL Yes No LUNGS Yes No GENITOURINARY Yes No NEUROLOGIC Yes No
Weight Loss or Gain Coughing Up Blood Incomplete Urination Headaches
Fever Shortness of Breath Loss of Urine Dizziness
Chronic Fatigue Chronic Cough Painful Urination Seizures
Excessive Bleeding Blood Clot in Lungs Bloody Urine Numbness
Easy Bruising Painful Breathing Frequent Urination Memory Loss
Increased Appetite Wheezing Night time Urination Fainting Spells
Increased Thirst CARDIOVASCULAR Yes No Discharges: Penis/Vagina Tremors
Excessive Sweating Chest Pain/Discomfort Unusual Vaginal Bleeding Loss of coordination
EYES, EARS, NOSE Yes No Irregular Heart Beat Sexual Function Problems MENSTRUAL PROBLEMS Yes No
Itchy, Red Eyes Palpitations MUSKULOSKELETAL Yes No Cramps/Pain
Vision Problems Ankle/Hand Swelling Muscle Weakness Heavy Bleeding
Frequent Colds Leg pain on walking Muscle Pain Too Frequent Periods
Bleeding Between
Nasal Congestion GASTROINTESTINAL Yes No Joint Pains
Periods
Ear Pain Frequent Diarrhea Joint Swelling Missed Periods
Ringing in Ears Constipation Clot in Leg Vein/Leg Pain BREAST PROBLEMS Yes No
Hearing Loss Blood in the Stools Varicosities Breast Pain
Sinus Problems Nausea/Vomiting Low Back Pain Breast Lump
Nose Bleeds Hemorrhoids SKIN Nipple Discharge
THROAT Yes No Abdominal pain Acne EMOTIONAL Yes No
Sore Throat Bloating Rash Excessive Worrying
Mouth Sores Indigestion Oily Skin Depression
Dental Problems Heartburn/Reflux Dry Skin Problems with sleep
Serious thoughts of
Change in bowel Change in Mole
Trouble swallowing harming yourself or
movement characteristic others

I certify that the above information are true and correct to the best of my knowledge. I understand that failure to disclose
pertinent personal medical information may affect the assessment and evaluation of any medical officer to my physical fitness to
perform my duties and functions.
I hold myself liable for perjury, falsehood, misrepresentation or omission, or act of dishonesty, if there is willful failure to
disclose pertinent medical information. I attest to the truthfulness of this undertaking and submit to the legal and administrative
consequences thereof if ever the statements above are wanting in truth and substance.

_____________________ ___________________________________
Date Signature Over Printed Name
Applicant
EVALUATOR:

________________________________________
Signature Over Printed Name
MEDICAL OFFICER
Page 3 of 3
 1CY2023_2023_Y360T4
PNPHS FORM 2020-01

Republic of the Philippines

National Police Commission
PHILIPPINE NATIONAL POLICE
HEALTH SERVICE
Camp PBGen Rafael T Crame, Quezon City

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR Q)

For Physical Agility Test (PAT)
DATE: _______________________

LAST NAME FIRST NAME MIDDLE NAME AGE SEX CIVIL STATUS

RONES JASON VILLANUEVA

NEXT OF KIN (NAME, RELATIONSHIP, ADDRESS, CONTACT NO.) CONTACT NUMBER

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE. This questionnaire is being given to the participant before any physical
activity or exercise. This may be used for legal and/or administrative purposes.
To be accomplished by the participant: Please read carefully and answer each one honestly: Check YES or NO.
YES NO
‫ﭪ‬ ‫ﭪ‬ 1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommend by a doctor?
‫ﭪ‬ ‫ﭪ‬ 2. Do you feel pain in your chest when you do physical activity?
‫ﭪ‬ ‫ﭪ‬ 3. In the past month, have you had chest pain even when you are not doing physical activity?
‫ﭪ‬ ‫ﭪ‬ 4. Do you experience shortness of breath or difficulty in breathing when doing physical activity?
‫ﭪ‬ ‫ﭪ‬ 5. Has any doctor ever said you have diabetes or increased blood sugar?
‫ﭪ‬ ‫ﭪ‬ 6. Have you had blood pressure over 140/90?
‫ﭪ‬ ‫ﭪ‬ 7. Do you lose balance because of dizziness or do you ever lose consciousness?
‫ﭪ‬ ‫ﭪ‬ 8. Do you have a bone or joint problem? For example knee or hip that could be made worse by a change in physical activity?
‫ﭪ‬ ‫ﭪ‬ 9. Have you had fever, cough, colds or even vehicular accident in the past week that required bed rest?
‫ﭪ‬ ‫ﭪ‬ 10. Do you know any other reason why you should not do any physical activity?

“I have read, understood and accurately completed this questionnaire. I attest that the above information are true and correct to
the best of my knowledge. I confirm that I am voluntary engaging in this physical agility test and my participation involves a risk
of injury. I understand that failure to disclose any pertinent medical information puts me at risk and can be held against me in my
PNP application”

___________________________________________ DATE:_____________________
Name/Signature of Applicant

FOR MEDICAL STAFF

BP 2nd BP 3rd BP ECG RESULT: Encircle:

GO
PR 2nd PR 3rd PR
NO GO
___________________________________
Signature over printed name of Medical Officer
 PNP HS MS FORM NO. 2014-02 Revised 2017

Republic of the Philippines

National Police Commission
PHILIPPINE NATIONAL POLICE
HEALTH SERVICE
Camp PBGen Rafael T Crame, Quezon City

PHYSICAL EXAMINATION REPORT

DATE: _______________________ CONTROL NO. - - - - - - - - - - -
RANK LAST NAME FIRST NAME MIDDLE NAME AGE SEX CIVIL STATUS
RONES JASON VILLANUEVA
PERMANENT HOME ADDRESS (NUMBER,STREET,CITY OR TOWN PROVINCE) CONTACT NUMBER

BADGE NO. DATE OF BIRTH PLACE OF BIRTH RELIGION PURPOSE OF EXAMINATION

LENGTH OF SERVICE UNIT ASSIGNMENT/ADDRESS

NEXT OF KIN (NAME, RELATIONSHIP, ADDRESS, CONTACT NO.)

THIS PART IS TO BE FILLED-UP BY MEDICAL STAFF/MEDICAL OFFICER

HEIGHT (cm) barefoot WEIGHt (kg) stripped COLOR OF HAIR COLOR OF EYES WAIST CIRCUMFERENCE BMI (weight in kg / height in meter
squared):

BLOOD PRESSURE (mmHg) HEART RATE (bpm) RESPIRATORY

DATE DATE DATE DATE DATE DATE
RATE (cpm)

1ST 2nd 3 rd 1ST 2nd 3 rd TEMP (°C)

NOTE: Describe every abnormality in detail. Enter number of pertinent item,

PHYSICAL EVALUATION before each comment. Use additional sheet if necessary.
EXAMINER’S
Check each item in appropriate column. NORMAL ABNORMAL
INITIALS
1. SKIN,LYMPHATICS
(identifying body marks, scars & tattoos)
2. HEAD,FACE, AND SCALP
3. NECK (mass, lymph nodes)
4. NOSE
5. MOUTH AND THROAT
6. EARS-GENERAL (int. & ext)
7. EAR DRUMS (perforation)
8. HEARING (WHISPER VOICE TEST)
RIGHT WV ____ / 15 LEFT WV ____ / 15
9. EYES (general appearance)
10. PUPILS (size, reactions), VISUAL FIELD
11. OCULAR MOTILITY (EOM)
12. DISTANT VISION
RIGHT __ - - /__ PINHOLE __/__
LEFT __/__ PINHOLE __/__
13. NEAR VISION
RIGHT J _____ LEFT J _____
14. COLOR VISION (ISHIHARA)
15. LUNGS AND CHEST (include breasts)
16. HEART (PMI, rhythm, murmur)
17. PERIPHERAL VASCULAR (varicosities)
18. ABDOMEN (note for hernia)
Page 1 of 2
1CY2023_2023_Y360T4
19. ANUS AND RECTUM
20. GENITALIA
21. UPPER EXTREMITIES (strength, range of motion)
22. LOWER EXTREMITIES(strength, range of motion)
23. SPINE, MUSCULOSKELETAL
24. NEUROLOGIC
FEMALES ONLY (check how done) 26. OBSTETRIC SCORE
G___ P ___ (__ __ __ __) ( ) NSD ( ) C/S
25. PELVIC
( ) VAGINAL ( ) RECTAL LMP ________________ ( ) ABORTION

CHEST X-RAY, ECG, AND LABORATORY EXAMINATION

CXRAY (PLACE, DATE, FILM NUMBER, RESULT) ECG (PLACE, DATE, INTERPRETATION)

HEMATOLOGY URINALYSIS BLOOD CHEMISTRY SEROLOGY

COMPLETE BLOOD COUNT FBS RPR / VDRL

CREA HBs Ag

OTHERS: ANTI-HBS
PREGNANCY TEST
ABO & RH BLOOD TYPE

OTHER TESTS/ANCILLARY PROCEDURES:

ADDITIONAL CLINICAL NOTES: PHYSICAL PROFILE SUFFIX

P U L H E S R T D O

SUMMARY OF DEFECTS NOTED/DIAGNOSIS (basis for disqualification):

RECOMMENDATIONS: PHYSICAL HEALTH

 PHYSICALLY FIT FOR POLICE SERVICE PROFILE
 FIT FOR POLICE SERVICE BUT WITH RESTRICTIONS, specify;_________________________
 TEMPORARILY UNFIT FOR POLICE SERVICE FOR ___________ MONTHS
 PERMANENTLY UNFIT FOR POLICE SERVICE

I hereby certify that I have seen and thoroughly examined this applicant together with his/her laboratory
results that lead to the above recommendation/s.

__________________________________ _____________________
SIGNATURE OVER PRINTED NAME DATE EVALUATED
MEDICAL OFFICER
Page 2 of 2
1CY2023_2023_Y360T4
 PNP HS FORM NO. 2014-05

2x2 colored picture with white

background and the name should
appear below the picture
Republic of the Philippines
National Police Commission
PHILIPPINE NATIONAL POLICE (LAST, FIRST, M.I. & BELOW IS THE
HEALTH SERVICE RANK).

Camp PBGen Rafael T Crame, Quezon City

CONTROL NO.___________________________________________

PE ROUTING SLIP AND INSTRUCTIONS

NAME: JASON VILLANUEVA RONES AGE/SEX:________________

ADDRESS: ________________________________________________________ CONTACT #: _________________

ÿ NEW APPLICANT
ÿ OLD APPLICANT: Date/Place of Last Application: ______________ __________________ No of Application: ________

______________________________________
Signature Over Printed Name of Applicant

a. Get the appropriate form for the desired examination

1ST STEP b. Fill up Medical History Form and other PE forms completely
c. Read instructions carefully
MEASUREMENTS DATE EXAMINER’S INITIAL

HEIGHT

WEIGHT
2ND STEP
WAISTLINE

BMI

BP

3RD STEP HEART RATE

RESPIRATORY RATE

4TH STEP GENERAL PHYSICAL EXAMINATION

With deficiency No deficiency
5TH STEP EAR EXAMINATION
Visual Acuity
Right Left
6TH STEP EYE EXAMINATION Snellen

7TH STEP EYE EXAMINATION Color Vision (Ishihara)

With deficiency No deficiency
8TH STEP DENTAL EXAMINATION

9TH STEP LABORATORY & X-RAY

10TH STEP ECG

REVIEW OF MEDICAL HISTORY, EVALUATION OF LAB, ECG AND

11TH STEP CXR RESULTS

12th STEP FINAL EVALUATION BY CHIEF MEDICAL DISPENSARY

Signature

1CY2023_2023_Y360T4
 1CY2023_2023_Y360T4
PNP HS FORM NO. 2014-07
2x2 colored picture with white
background and the name should
Republic of the Philippines appear below the picture
National Police Commission
PHILIPPINE NATIONAL POLICE (LAST, FIRST, M.I. & BELOW IS THE
HEALTH SERVICE RANK).
Camp PBGen Rafael T Crame, Quezon City

CONTROL NO.__________________

DOCTOR’S WORK SHEET

NAME: JASON VILLANUEVA RONES
AGE/SEX:________________

To be filled up by PE Section Medical Staff:

EXAMINER’S CHECK
STEPS DATE INITIAL
FINDINGS/RESULT REMARKS IF OK

MEDICAL HISTORY FORM

MEASUREMENTS HEIGHT

WEIGHT

BMI

WAIST CIRCUMFERENCE

1ST 2ND 3RD

BP

1ST 2ND 3RD

HEART RATE

RESPIRATORY RATE

GENERAL PHYSICAL EXAM

GENERAL EYE EXAM

VISUAL ACUITY

COLOR VISION TEST (Ishihara)

EAR EXAM

ECG

CHEST X-RAY

DENTAL

LABORATORY

REVIEWED BY: RECOMMENDED / NOT RECOMMENDED

_________________________________________________
SIGNATURE OVER PRINTED NAME
MEDICAL OFFICER
 CONFIDENTIAL

PERSONAL HISTORY STATEMENT

FILE NR______

INSTRUCTIONS

1. Answer all questions completely; if question is not applicable write “NA”.

Write “Unknown” only if you do not know the answer and if the answer cannot be
derived from personal records. Use the blank pages at the back of this form for extra
details on any question for which you do not have sufficient space.

2. Type, print, or write carefully; illegible or incomplete forms will not receive
due consideration.

WARNING

1. The correctness of all statements of entries made herein may be

ascertained through investigation.

2. Any deliberate omission or distortion of information may give sufficient

cause for denial of clearance and unfavorable result of the investigation.

3. The statements made herein are classified CONFIDENTIAL. Revelation

or use other than the authorized purpose is prohibited by PNP security policy.

I. PERSONAL DETAILS

Name:
Rank:
Present Job/Assignment
Business or Duty Address:
Home Address (Include Street & No.)

Birth date: Birthplace:

Change in Name (If by Court Action, give details):

Nicknames: Nationality:
TIN: SSS ID No.:
PAG-IBIG ID No.: Phil Health ID No.:
GSIS ID No.: Other Details:
II. PERSONAL CHARACTERISTICS

Sex: Age: Height: (meter)

Weight: (kg) Build:
Complexion (Dark, Fair, Light): Color of Eyes:
Color of Hair:
Scars or Marks and other distinguishing features:

Other Details:

III. MARITAL HISTORY

A. Marital Status (Single, Married, Separated or Widowed):

Name of Spouse (Full Name):
Date & Place of Marriage:
Birth date:
Birthplace:
Occupation and Place of Employment:
Signature: ______________________ Date: ______________________
PNP Transformation: “Our shared commitment to deliver effective and efficient police services”.

CONFIDENTIAL
 CONFIDENTIAL

Other Details:

B. Children:
Name Date of Birth Citizenship and Address

Other Details:
IV. FAMILY HISTORY AND INFORMATION

A. Father:
Date of Birth:
Place of Birth:
Address:
Occupation and Place of Employment:
Citizenship (If naturalized, give date and place where naturalized):
Other Details:
B. Mother:
Date of Birth:
Place of Birth:
Address:
Occupation and Place of Employment:
Citizenship (If naturalized, give date and place where naturalized):
Other Details:
C. Brothers and Sisters:
Name Age Address Occupation

Other Details:
V. EDUCATIONAL BACKGROUND

Level Name of Location Inclusive Year Awards

School Date of Graduated Received
Attendance
Elementary

High School

College

Post Graduate

Other Schooling
Eligibility (Career Service / RA 1010-Board or Bar (CES/CSEE) and other similar
qualifications required:

Signature: ______________________ Date: ______________________

PNP Transformation: “Our shared commitment to deliver effective and efficient police services”.

CONFIDENTIAL
 CONFIDENTIAL

VI. PLACES OF RESIDENCE SINCE BIRTH

Inclusive Dates Addresses Name of at least two (2)

Neighbors

VII. UNIT ASSIGNMENT SINCE ENTERED THE PNP

Position Date Unit Qualifications

VIII. PNP TRAININGS/SEMINARS ATTENDED

Title of Date of Nature of Conducted Awards Received

Training/Seminar Attendance Training by

IX. EMPLOYMENT

Inclusive Type of Name/Address of Employer Reason for

Dates Employment Leaving

Have you ever been dismissed or forced to resign from a position? YES__ NO__
If yes, state the reason/s.

Signature: ______________________ Date: ______________________

PNP Transformation: “Our shared commitment to deliver effective and efficient police services”.

CONFIDENTIAL
 CONFIDENTIAL

X. A. FOR POLICE COMMISSIONED OFFICERS ONLY

Source of Commission/ Please Year Indicate the Date and Number of

Entry to the Officers Check Appointment Order
Corp
PMA
PNPA
AFP Reserve
Lateral Technical
Lateral Line
SPO4 – INSP
NAPOLCOM
Others, please specify:

B. FOR POLICE NON-COMMISSIONED OFFICER & NON-UNIFORMED

PERSONNEL
Date Entered the PNP Appointment Order Number

XI. FOREIGN COUNTRIES VISITED

Date Country Visited Purpose of Visit

XII. CHARACTER REFERENCE

A. Give five (5) character references (known three years or longer, who are not related to
you)
Name Address and Telephone Number

B. List down three (3) neighbors at your present address:

XIII. PLEASE COPY IN OWN HANDWRITING

“Our London business is good, but Vienna and Berlin are quite. Mr. D. Lloyd has
gone to Switzerland. He will be staying at 1946 Zernatt St. for a week and will be going to
Turnie and Rome joining Police Superintendent Perry.

XIV. ORGANIZATION

List organization or social groups which you have been a member of:
Organization Address Date of Membership & Position
Held

Signature:_______________ Date:_____________________

PNP Transformation: “Our shared commitment to deliver effective and efficient police services”.

CONFIDENTIAL
 CONFIDENTIAL

XV. ADMINISTRATIVE/CIVIL/CRIMINAL OFFENSE DATA

OFFENSE COMMITTED AS TYPE CHARGE DISPOSITION

CHARGED (State whether (Exonerated, convicted,
admin/civil/criminal and pending)
date) (State penalty if convicted)

XVI. MISCELLANEOUS

A. Are you entirely dependent on your salary? YES__ NO__ If No, please state the other
source of income:
B. Have you filed a Statement of your Assets and Liabilities with any government agency:
YES__ NO__ If so what agency?
C. Have your latest income tax return? YES__ NO__ If Yes, amount paid for the last
calendar year:
D. Do you use intoxicating liquor or narcotics? YES__ NO__ If Yes, to what extent?
E. Languages or dialects:

F. Hobbies, sports and past time:

XVII. CERTIFICATION

I certify that the foregoing answers are true and correct to the
best of my knowledge and belief and I agree that any misstatement
or omission as to material fact will constitute ground for immediate
denial of my application for clearance.
Signed at: Date:

(2 x 2)
Photo

(Witness) (Witness)

THUMBMARKS

________________________
Signature of Applicant Left Right

Subscribe and sworn to before me this ____ day of ____________, ______

At ________________, Philippines, affiant exhibited to me his/her residence certificate No.
__________ issued on _____________, _______ at ________________________,
Philippines.

_____________________________
(Administrative Officer/Notary Public)
_______________________
(Rank and Designation)

Signature: ______________________ Date: ______________________

PNP Transformation: “Our shared commitment to deliver effective and efficient police services”.

CONFIDENTIAL
Recruitment Process QR Code

1CY2023_2023_Y360T4
Recruitment CY 2023