CONFIDENTIAL

 Republic of the Philippines

NATIONAL POLICE COMMISSION
PHILIPPINE NATIONAL POLICE
NATIONAL CAPITAL REGION POLICE OFFICE
REGIONAL INTELLIGENCE DIVISION
Camp Bagong Diwa, Bicutan, Taguig City

February 13 2023
Date

APPLICATION FOR SECURITY CLEARANCE

INSTRUCTIONS:

1. Pursuant to PNP Security Policy, all PNP personnel who have need or
who has access to PNP classified matter shall be required to obtain clearance from the
Directorate for Intelligence, PNP and other authorized clearing authorities. This form is
intended to expedite the issuance of such clearance.

2. Attach the Personal History Statement duly administered by a notary

public/official authorized to administer oath.

3. Joint Security Statement from two (2) disinterested employees who have
at least three (3) years continuous service is required (PART B).

4. This application shall be endorse by official communication by the head

of office or unit through channels by mail or courier to DI, PNP (Attn: CSD), Camp
Crame, Quezon City in two (2) copies.

5. In order to facilitate the issuance of clearance, the head of office or unit

should endeavor to guarantee that the applicant has no involvement in activities inimical
to the security of the state.

PART A – IDENTIFICATION:

Name of Applicant: Jet-lin Zuñiega Perez

Rank:Police Staff Sergeant Badge Number: 231621

Name of Unit/Office: Tactical Motorcycle Rider’s Unit/ Valenzuela City Police

Station
Position/Designation: Motorcycle Patroller

Date of Birth: August 14, 1982 Place of Birth: Caloocan City

Address: 371 General Luis Street Caybiga Caloocan City

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PART B – JOINT SECURITY STATEMENT:

We, the undersigned co-employees of

Jet-lin Zuñiega Perez hereby declare:

(Name of Applicant)

1. That we have been employed/assigned in this Unit/Office for three (3)

continuous years;

2. That we have known the applicant personally for at least three (3) years; and

3. That as per our knowledge and belief, there exists no derogatory which
reflect on the character and loyalty of the applicant to the Philippine National Police and
other government agencies.

Signature: _______________________________ _________________________

Rank/Name: PSMS Perillo Jacques John Rosantina Villanueva Percy Jr. Simangan
Designation: Motorcycle Patroller. Shift Supervisor

PART C – SECURITY CERTIFICATION OF THE HEAD OF OFFICE OR

THE DESIGNATED SECURITY OFFICER

This is to certify that pursuant to official record/s of this Unit/Office, and to my

personal knowledge, no derogatory information exists which reflect on the character and
loyalty of Jet-lin Zuñiega Perez. Applicant was last issued security clearance on
N/A(mark “NA” if new application). It is further certified that the applicant has rendered
continuous service with this Office since April 08,2022.

Signature: __________________________________
Rank/Name: PCPT DODDIE MELRIN AGUIRRE
Designation: OIC Sub-Station 4
Date: February 13, 2023

Date: February 13 2023

PART D – SECURITY DECLARATION OF THE APPLICANT

I hereby certify that I shall use my authority for access to classified matter for
official purposes only; that all such materials that may be made available to me
through my clearance will be handled in accordance to applicable laws, rules and
regulations; and that no information received will be divulged to persons and
entities who are not similarly cleared nor have the need-to-know for such access.

Signature: __________________________________
Rank/Name: Police Staff Sergeant
Designation: Motorcycle Patroller

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 CONFIDENTIAL
Republic of the Philippines
NATIONAL POLICE COMMISSION
PHILIPPINE NATIONAL POLICE
NATIONAL CAPITAL REGION POLICE OFFICE
REGIONAL INTELLIGENCE DIVISION
Camp Bagong Diwa, Bicutan, Taguig City

SECURITY DECLARATION

I, Jet-lin Zuñiega Perez, of legal age, employed or assigned with Tactical Motorcycle
Rider’s Unit do hereby declare and affirm:
(State specific unit and assignment in the PNP)

1. That I shall be responsible in preserving the security of all classified information which
may be imparted to me as a result of my employment in the Philippine National Police (PNP),
and undertake to comply which such regulations concerning as from time to time be laid down;

2. That I shall not divulge any classified information acquired by me to any unauthorized
person, either verbal or written form;

3. That I shall not, without the authority of the Chief, PNP, publish any classified
information which I had acquired or to which I have access owing my position whether orally or
in any document, article, book, film or otherwise;

4. That I shall, upon relief/transfer or retirement, surrender any classified sketch, plan,
model, article, note, security tag/badge, or document made or acquired by me in the course of
my official duties;

5. That should I fail to safeguard classified information, I can be liable to lose my security
clearance and face prosecution under the Revised Penal Code and Presidential Decree 51, and
be declared as a security risk;

I hereby certify that I have read and fully understood the contents of my security
declaration and I am aware of my responsibility for safeguarding PNP classified information.

I hereby further certify that I fully understood that the provisions of this security
declaration apply not only during the period of my employment with the PNP shall have
ceased. That I am liable to prosecution under the Revised Administrative Code, Presidential
Decree 51, and other existing laws and regulations of the Republic of the Philippines , if by
intent or negligence, I allow classified information to pass unto unauthorized hands.

Signature: __________________________________
Name: Jet-lin Zuñiega Perez
Rank: Police Staff Sergeant

SUBSCRIBED AND SWORN to before me this 13 day of February, 2023.

PCPT DODDIE MELRIN AGUIRRE

Administering Officer

Copy furnished:
Directorate for Intelligence

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