1
PERSONAL HISTORY STATEMENT
INSTRUCTIONS:
To be submitted by the applicant foreign student in 5 copies in applying for a student visa to the Dean of
Admission of the accepting higher education institution.
(DO NOT LEAVE ANY SPACE BLANK)
___________________________________________________________________________________
Last Name
First Name
M. I.
Name in Chinese characters: (If applicable) ________________________________________________
Sex : ______
Height
: _____ (cms) Weight
: ________ (kg)
Eyes: ______
Hair
: __________ Complexion : ___________
Built: __________
Age : ______
Date of Birth: __________ Place of Birth: ______________________________
Citizenship
If married, name of spouse
: _______________________________________________
If married woman, state maiden name
: _______________________________________________
Other distinguishing features
: _______________________________________________
Permanent Home Address
: _______________________________________________
Philippine Address
: _______________________________________________
Guarantors Name
: _______________________________________________
Guarantors Address (Philippines or Abroad): _______________________________________________
________________________________________________
Sponsoring organization
: _______________________________________________
Address
: _______________________________________________
Name of Father : __________________________ Address: __________________________________
Name of Mother: __________________________ Address: __________________________________
Name of nearest relative in the Philippines : _______________________________________________
Address: ___________________________________________________________________________
EDUCATIONAL BACKGROUND:
School
Inclusive Date
Course Taken
When Graduated
Elementary
High School
College
Post Graduate
EMPLOYMENT HISTORY: History of Employment. State whether on a permanent, temporary or casual
basis. Include employment by a foreign government.
Inclusive Dates
Position
Employer
Employment Address
Cause of Separation
CLUBS, SOCIETIES AND ORGANIZATIONS: List names and address of all clubs, societies, employee
groups, organization. Include foreign or international organization. ______________________________
___________________________________________________________________________________
CHARACTER AND CREDIT REFERENCES: Give the names of three (3) persons who know you
intimately in your country. (Do not give name of relatives, employers or supervisors)
Name
Address
RESIDENCE OF MORE THAN SIX (6) MONTHS DURING THE LAST TWO (2) YEARS:
Inclusive Dates
Complete Home Address Abroad or Philippines
TRAVEL ABROAD:
Inclusive Dates
Countries and Address
Purpose
MILITARY SERVICE:
What Country : ____________________________________________ Highest Rank: ____________
Association : ______________________________________________________________________
MILITARY HISTORY: (Use additional sheet if necessary)
Date
Rank
Position
Purpose
GENERAL QUALIFICATION: Language and degree of proficiency (Oral or Written):
___________________________________________________________________________________
___________________________________________________________________________________
Hobbies: __________________________________________
Sports: ________________________
Skills : _____________________________________________________________________________
___________________________________________________________________________________
Honors and Awards
: _________________________________________________________
Publications and Invention
: _________________________________________________________
Physical Handicap or Disability : _________________________________________________________
CRIMINAL RECORDS:
Have you been arrested, indicted or convicted or any violation of law in your country? _________
___________________________________________________________________________________
GENERAL INFORMATION:
Have you been afflicted with loathsome dangerous disease? If so, state the nature: ___________
___________________________________________________________________________________
What is your sole purpose in coming to the Philippines? _________________________________
Are you willing to wait for the issuance of your visa at the Philippine Embassy/Consulate abroad
located in your country? _______________________________________________________________
Are you willing to abide with all the laws in the Philippines? ______________________________
I CERTIFY THAT I ACCOMPLISHED THIS FORM PERSONALLY IN MY OWN HANDWRITING
AND THAT THE FOREGOING ANSWERS ARE TRUE AND CORRECT TO THE BEST OF MY
KNOWLEDGE AND BELIEF.
Signed at ________________________________
Date: _________________________
THUMBMARK
________________________
Signature of Student-Applicant
LEFT
RIGHT
2x2
PHOTOGRAPH
