Republic of the Philippines

Department of the Interior and Local Government

National Police Commission
NATIONAL HEADQUARTERS PH1L[PPfNE NATIONAL POLICE
CRIME LABORATORY
Camp Crame, Quezon City

QU ESTIONED DOCU ME i T EXAM IN ATION DI VI SION

(INSTRUCTION: Please use pen in filling-up this form)

(Date)

(FAMILY (GIVEN NAME) (Maternal) (Qual ifier) (Nickname)

NAME)

Address:
(Street) (Province)

Nationality: Citizenship: Civil Status:

(Place of Birth) (Date of Birth) (Age) (Sei)

Last School Attended: Address:

Highest Educ Attainment: Degree:

Living with: Maiden Name:

Nationality oF Spouse: Occupation of Spouse:

cast Employer: Present Occupation:

Name of Nearest Relative: Present Address:

WRITE ALL THE LETTERS OF THE ALPHABET

1 . Small letters (in iong hand)

2. Small leners (script writing)

3. Capital letters (in long hand)

4. Capital letters (in block writing)

5. Write Number 1 to 10

1. Name in long hand:

2. Name in block writing:

3. Did you write with your left or right hand?

COPY EXACTLY IN YOUR OWN HANDWRITING THE WHOLE PARAGRAPH BELOW:

As Leonardo Luis E. Rapazo III on 105* Xavier guzzled his way through three (3)
bottles of brandy, Mary Josephine Z. Quinzing, a partner in the Quezon City turned to John
Richard Dick Ting Sr., a Chinese Food expert from Q.C. Kuantong Company Ltd. 346 Hadji
Jairula Hussein Blvd., and said: I can’t speak for my government but I’m quite sure your
Company and mine better get together for closer understanding.

I HEREBY CERTIFY that the above data are true and correct and that the writing
appearing hereon are my true and genuine handwriting

(Signature)

(Signature)

Pfepmed in the presence of: 1) _

(Name in print & Signature)

2)
(Name in print & Signature)

SUBSCRIBED AND SWORN to before me this day of

200 at

RIGHT HAND THUMBMARK

WARNING: FALSIFICATION IS CRIMINAL OFFENSE AND PUNISHABLE UNDER

THE REVISED PEDAL CODE.
(Note: A Copy of this document is retained by Questioned Document Examination Division for
rerord and reference.}