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    Personnel Security Questionnaire: Personal Information

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    Charisse Mae Rillorta
    Juan Dela Cruz has applied for a plant tour visit with Philippine Long Distance Telephone Company. He completed a personnel security questionnaire providing personal details like his name, date of birth, address, education history and references. He certified that the information provided was true and understood any misrepresentation could result in administrative action. A personnel security investigator will review the form and determine if Juan receives security clearance for the plant tour.

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    Personnel Security Questionnaire: Personal Information

    Uploaded by

    Charisse Mae Rillorta
    30 views2 pages
    Juan Dela Cruz has applied for a plant tour visit with Philippine Long Distance Telephone Company. He completed a personnel security questionnaire providing personal details like his name, date of birth, address, education history and references. He certified that the information provided was true and understood any misrepresentation could result in administrative action. A personnel security investigator will review the form and determine if Juan receives security clearance for the plant tour.

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    Juan Dela Cruz has applied for a plant tour visit with Philippine Long Distance Telephone Company. He completed a personnel security questionnaire providing personal details like his name, date of birth, address, education history and references. He certified that the information provided was true and understood any misrepresentation could result in administrative action. A personnel security investigator will review the form and determine if Juan receives security clearance for the plant tour.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    30 views2 pages

    Personnel Security Questionnaire: Personal Information

    Uploaded by

    Charisse Mae Rillorta
    Juan Dela Cruz has applied for a plant tour visit with Philippine Long Distance Telephone Company. He completed a personnel security questionnaire providing personal details like his name, date of birth, address, education history and references. He certified that the information provided was true and understood any misrepresentation could result in administrative action. A personnel security investigator will review the form and determine if Juan receives security clearance for the plant tour.

    Copyright:

    © All Rights Reserved
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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 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

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