PSC Form (Revised 2019)

PROFILE FORM - ATHLETE

* Kindly accomplish this form and submit to NSA Affairs Office with complete details. Indicate N/A if not applicable.
** Photocopy of Birth Certificate and passport must be attached to this form

SPORT PENCAK SILAT EVENT/CATEGORY TANDING CLASS A

NAME OF COACH ALEXIUS MARTIN Q. PATANO
CLASSIFICATION ATHLETE
PERSONAL INFORMATION
SURNAME CAMPOS
NAME EXTENSION (JR., SR)
FIRST NAME ALVIN
MIDDLE NAME TANILON

NATIONAL POOL SINCE 4/10/2016 CITIZENSHIP

DATE OF BIRTH
(mm/dd/yyyy) 9/12/1994 FILIPINO PHILIPPINES

PLACE OF BIRTH ZAMBOANGUITA NEGROS ORIE If holder of dual citizenship, Pls. indicate country:
please indicate the details.
SEX MALE

CIVIL STATUS PROVINCIAL ADDRESS BRGY. BATO

SINGLE
House/Block/Lot No. Street/Subdivision/Village
BASAK ZABOANGUITA NEGROS ORIENTAL NEGROS ORIENTAL
Barangay/City/Municipality Province
RESIDENTIAL ADDRESS NEGROS ORIENTAL
House/Block/Lot No. BATO BASAK

PSC ID NUMBER PENO15-2018

Barangay/City/Municipality BATO BASAK SAMBOANGUITA ZAMBOANGUITA

HEIGHT (m) 5'7 WEIGHT (kg) 70

PASSPORT NUMBER P0862932A PASSPORT VALID UNTIL JUNE.2021 LANDBANK ACCOUNT NUMBER 1777 1117 40
CONTACT NUMBER
TELEPHONE NUMBER EMAIL ADDRESS

MOBILE NUMBER 09367319175 [email protected]. COM

FAMILY BACKGROUND
SPOUSE'S NAME (Surname, NAME of CHILDREN (Write full name and list all)
DATE OF BIRTH
First Name, Middle Name) (mm/dd/yyyy)

OCCUPATION

EMPLOYER/BUSINESS NAME

TELEPHONE NO.

FATHER'S NAME (Surname, MARBEN CAMPOS

First Name, Middle Name)
MOTHER'S NAME (Surname,
First Name, Middle Name)
GERLIE CAMPOS
(Continue on separate sheet if necessary)

HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE PERIOD OF LEVEL/
YEAR
SCHOLARSHIP
ATTENDANCE UNITS / ACADEMIC
LEVEL (Write in full) EARNED
GRADUATED
HONORS
(Write in full) (if not RECEIVED
From To graduated)
CALANGO ELEMENTARY ATHLETE
ELEMENTARY 6/3/2003 3/28/2010 OF THE
VOCATIONAL / SCHOOL
SECONDARY
JOSE MARIE LOCSIN 6-3-210 3/29/2014 YEAR, 4TH
MEMORIAL HIGSCHOOL HONORAB
LE
MENTION
COLLEGE
PCCR PHILIPPINE COLLEGE OF BS. CRIMINOLOGY 83
CRIMINOLOGY
TRADE COURSE
GRADUATE STUDIES

SPECIMEN SIGNATUREOF ATHLETE DATE FEBUARY10.2019

SOLDIER-ATHLETE INFORMATION (For Enlisted Personnel Only)

UNIT BADGE NUMBER

page 1 of 2
INTERNATIONAL ACHIEVEMENT (starting with the most recent) *Please attach certification

YEAR NAME OF COMPETITION COUNTRY / VENUE MEDAL / RANK (Indicate COACH

number of participants)

2017 3RD ASIAN PENCAK SILAT CHAMPIONSHIP COREA SILVER COACH ALEX PATANO
2018 18TH -PRE-ASIAN GAMES INDONESIA BRONZE COACH ALEX PATANO

(Continue on separate sheet if necessary)

LOCAL ACHIEVEMENT (starting with the most recent) *Please attach certification

YEAR NAME OF COMPETITION COUNTRY / VENUE MEDAL / RANK (Indicate COACH

number of participants)
2014 SULTANS CUP MABINAY MABINAY GOLD SOLOMON ELUNA
2015 SULTANS CUP DUMAGUETE DUMAGUETE GOLD SOLOMON ELUNA
2015 PNG VESAYAS LEG ANTIQUE SELVER SOLOMON ELUNA
2016 PNG NATIONAL CHAMPIONSHIP MARIKINA BROZE SALOMON ELUNA

(Continue on separate sheet if necessary)

I declare under oath that I have personally accomplished this Athlete Profile Form which is a true, correct and complete statement pursuant to the provisions of
pertinent laws, rules and regulations of the Republic of the Philippines. I authorize PSC and other government agencies to verify/validate the contents stated
herein. I agree that any misrepresentation made in this document and its attachments shall cause the filing of administrative/criminal case/s against me.

2/10/2019
SIGNATURE OF ATHLETE DATE ACCOMPLISHED
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