PDEA

DEO Form - 2012

2012 - 06

Republic of the Philippines

OFFICE OF THE PRESIDENT
PHILIPPINE DRUG ENFORCEMENT AGENCY
PDEA Building, NIA Northside Road, National Government Center
BARANGAY Pinyahan, Quezon City, 1100

PDEA AGENT APPLICATION FORM

Region
Contact No.
E-mail Add:
Warning:
All statement or entries made herein are subject to verification and any deliberate error or distortion of information may give sufficient cause for
investigation

I. GENERAL INFORMATION
1. NAME: (Last Name First Name Middle Name Qualifier)

2. HOME ADDRESS (House No. Street Brgy. Municipality / City Province)

4. Date of Birth

3.Zip Code (Mandatory)

5. Place of Birth

6. Sex:

7. Height:

8. Weight:(kg)

9. Civil Status:

10. TIN No.

11. GSIS No.

12. PAG-IBIG No.

13. PHILHEALTH No.

14. SSS ID No.

15. Color of Hair

16. Color of Eyes:

17. Citizenship:

18. Religion:

19. Blood Type

20. Built

21.Complexion:

22. Language

23. Ethnic Group

24. Identifying Marks

25. In case of emergency : (Name / contact No. Address)

II.EDUCATIONAL BACKGROUND
Name of School
(write in full)

26. Level

Degree Course
(write in full)

Highest Grade
Level Units
earned (if not
graduated)

Inclusive
Date of
Attendance
From
To

Scholarship
Academic
Honors
Received

Vocational/
Trade Course
College
Graduate
Studies
III. CIVIL SERVICE ELIGIBILITY
27. Civil Service/RA 1080 (Board/Bar) Under
Special Laws / CSEE

Rating

Date of Examination

Place of
Examination/
Conferment

License (if Applicable)

Number

Date of Release

IV.WORK EXPERIENCE(Include Private Employment Start with your Current work)

28. Inclusive dates
(mm/dd/yyyy)
From

Position Title
To

Status of
Department/Agency/ office/Company
Monthly Salary Salary Grade Appointment
(write in full)

Government
Service (Yes/No)

VII. OTHER INFORMATION

29. Other Skills Talents and Hobbies

Non-Academic Recognitions

30. Are you related by consaguinity or affinity to any of the following

a. Within the thrid degree (for National Government Employee):
Appointing authority, recommending authority, chief of office/bureau/

Membership in Association/Organization (write in full)

Yes No
If YES, give details:

department or persons who has immediate supervision over you in

the office, Bureau or department where you will be appointed?
b. within the fourth degree (for Local Government Employees):

Yes No

Appointing authority or recommendinf authority where you will be

If YES, give details:

appointed?
31
a. Have you ever been formally charged?

Yes No
If YES, give details:

b. Have you ever been guilty of any administrative offense?

32

Yes No

Have you ever been convicted of any crime or violation of any law, decree,
ordinance or regulations by any court or tribunal

Yes No
If YES, give details:

33

Have you ever been forced to retire, resign or be dropped fromemployment

in the publicor private sector?

Yes No
If YES, give details:

34

Pursuant to: (a) Indigenous People's Act (RA 8371): (b) Magna Carta for
Disabled Persons (RA 7277); and (c) Solo Parents Welfare Actof 2000 (8972)
please answer the following items:

Yes No

a. Are you a member of any indigenous group?

Yes No

If YES, give details:

If YES, give details:

b. Are you a differently abled?

Yes No
If YES, give details:

c. Are you a solo parent?

Yes No
If YES, give details:

35

REFERENCE (Person not related by consanguinity or affinity to applicant/appointee)

NAME
ADDRESS

TELEPHONE No.

36

I declare under oath and subject to the penalties of perjury that this PDEA Application Form has been accomplished in good faith and verified by me and
to the best of my knowledge and belief is true, correct and complete satement pursuant to the provision of pertinent laws, rules and regulations of the
Republicof the Philippines.

37

I also authorize the agency/authorized representative to verify/validate the contents herein. I trust that this information shall remain confidential

COMMUNITY TAX CERTIFICATE

ISSUED AT
ISSUED ON (MM/DD/YYYY)
DATE ACCOMPLISHED