PERSONNEL SECURITY QUESTIONNAIRE
Philippine Long Distance Telephone Company
Special Operations Division
(Plant Tour Visits)
INSTRUCTIONS: Copies of the accomplished form will be carefully examined by Special Operations
Division. Print all answer. If more spaces are required, attach additional sheets, identifying by
corresponding block no. Form will not be accepted unless completely and properly filled. Questions, which
do not apply, will be marked not applicable (NA) or unknown if answers cannot be obtained from personal
records.
WARNINGS: Failure to answer all questions or any misrepresentation (by omission or concealment, or
any misleading, false or partial answer) may serve as basis for appropriate administrative action.
Personal Information
Family Name: First Name: Middle Name:
DELA CRUZ JUAN TWO
Height: Weight: Hair:
Sex:
165 cm 85 kg BLACK
Male Female
Eyes: Social Security Number: Tax Identification Number: Drivers License Number:
BLACK N/A N/A N/A
Present Nationality: Date of Birth: Place and country of Birth:
FILIPINO 01 JAN 1990 SAN FERNANDO, LA UNION
Address: Telephone:
123 CARLATAN, SAN FERNANDO CITY, LA UNION 072-700-2500
List all names (aliases and nicknames) you have used or have been known by (include maiden name).
NA
Marital status: Single Married Separated Widow(er) Divorced
List the current address where you physically reside (mailing address).
Number, Street and Apt. No. Barangay/Sitio: Municipality/City. Zip Code:
123 CARLATAN SAN FERNANDO CITY 2500
List your residence, school and work phone numbers (include area codes and extensions if applicable).
Residence Tel No. (area code) 072-700-2000 School/Work Tel. No. (area code) 072–700-2000
Family Information
Father’s Name: Living Deceased Date and Place of Birth Occupation:
DELA CRUZ, JOHN HOUSEHUSBAND
Present Address: 123 CARLATAN, SAN FERNANDO CITY, LA UNION
Mother’s Name: Living Deceased Date and Place of Birth Occupation:
DELA CRUZ, JANE 01 JAN 1990, ILOCOS SUR HOUSEWIFE
Present Address: 123 CARLATAN, SAN FERNANDO CITY, LA UNION
Names of Brothers and Sisters.
Name Date of Birth Relationship
DELA CRUZ, PEDRO 01 JAN 2000 BROTHER
DELA CRUZ, JUANA 01 JAN 2010 SISTER
1
Education
From To
(month/year) (month/year) Institution (name, place) Certificate, degree obtained
JAN 1995 JUN 2000 Primary School: Graduate
LORMA COLLEGES
JAN 2000 JUN 2005 Secondary: Graduate
LORMA COLLEGES
JAN 2005 JUN 2010 College: Graduate
LORMA COLLEGES
Criminal / Administrative Derogatory Information
Have you ever been arrested, indicated, or summoned into court as a defendant in a criminal proceeding, or convicted, fined or
imprisoned for any law? If “yes”, give full particulars of each case in an attached statement. NO
Have you ever been charge in any administrative case? If “yes”, give full particulars of each case in an attached statement.
NO
Have any of your family ever been charge in any criminal or administrative case? If “yes”, give full particulars of each case in an attached
statement. NO
References (list three persons not related to you)
Name Company/Home Address Occupation, title Telephone No.
RODRIGO DUTERTE SAN FERNANDO, LA UNION DRIVER 0911.234.5678
SARA DUTERTE SAN FERNANDO, LA UNION INSPECTOR 0911.234.5678
GLORIA ARROYO SAN FERNANDO, LA UNION CONDUCTOR 0911.234.5678
Specimen Signatures Right Thumb mark Left Thumb mark
1.
2.
3.
CERTIFICATION:
I hereby certify that answers made to the forgoing questions are true, complete and correct to
the best of my knowledge and belief and I further agree, that any misrepresentation or false
statement made by herein may subject myself to appropriate administrative action.
JUAN DELA CRUZ
Signature over printed name
SECURITY CLEARANCE
(Note: This portion will be accomplished by a Personnel Security Investigator)
Access Authorization: Validity of Clearance:
SECURITY CLEARANCE:
Cleared Not Cleared
_____________________________
Personnel Security Investigator
