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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 ID Picture
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
2x2
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:

Sex: Height: Weight: Hair:


Male  Female 

Eyes: Social Security Number: Tax Identification Number: Drivers License Number:

Present Nationality: Date of Birth: Place and country of Birth:

Address: Telephone:

List all names (aliases and nicknames) you have used or have been known by (include maiden name).

Martial 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:

List your residence, school and work phone numbers ( include area codes and extensions if applicable).

Residence Tel No. (area code) School/Work Tel. No. (area code)

Family Information
Father’s Name: Living Deceased Date and Place of Birth Occupation:

Present Address:

Mother’s Name: Living Deceased Date and Place of Birth Occupation:

Present Address:

Names of Brothers and Sisters.


Name Date of Birth Relationship

Education
From To Institution (name, place) Certificate, degree obtained
(month/year) (month/year)
Primary School:

1
Secondary:

College:

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.

Have you ever been charge in any administrative case? If “yes”, give full particulars of each case in an attached statement.

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.

References (list three persons not related to you)


Occupation, title Telephone No.
Name Company/Home Address

Right Thumbmark Left Thumbmark


Specimen Signatures
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.

_________________________
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