CONFIDENTIAL

AMANDA’S
“SPICY BAGOONG”

AMANDA’S
“SPICY BAGOONG”

AMANDA’S
“SPICY BAGOONG”

AMANDA’S
“SPICY BAGOONG”

AMANDA’S
“SPICY BAGOONG”

CONFIDENTIAL
pplicant)
licant)

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C. BROTHERS AND SISTERS:

NAME DATE OF CITIZENSHIP COMPLETE ADDRESS OCCUPATION EMPLOYER

BIRTH (IF DUAL, WRITE BOTH)

D. STEP PARENTS OR GUARDIAN: Vicente A Santiago _

(Full Name)

Date and Place of Birth: Gov.RamosSta.Maria Zamboanga City

Complete Address: N/A ___ ___
Occupation/Employer/Place of Employment: N/A ___
___
Citizenship: _N/A _If dual, write both citizenship, if naturalized, give date and place
where naturalized ___

E. FATHER-IN-LAW: ____________________________ ___

(Full Name)

Date and Place of Birth: ___ ___ ___

Complete Address: __________________________________ ___
Occupation/Employer/Place of Employment: N/A ___
Citizenship: FilipinoIfdual, write both citizenship, if naturalized, give date and place
where naturalized ___
(Signature of Applicant)

F. MOTHER-IN-LAW: ___________________________________ ___

(Full Name)

Date and Place of Birth: ___ ___

Complete Address: ____________________________________________ ___
Occupation/Employer/Place of Employment: N/A ___
Citizenship: Filipino Ifdual, write both citizenship, if naturalized, give date and place
where naturalized ___
V. EDUCATIONAL BACKGROUND:

A. Elementary:

NAME OF SCHOOL LOCATION DATE OFYEAR

ATTENDANCEGRADUATED

Sta.Maria Elem SchoolSta.Maria Z.C6 Yrs 2006__

_ _________

B. High School:

NAME OF SCHOOL LOCATION DATE OFYEAR

ATTENDANCEGRADUATED

Don Pablo High SchoolSta.Maria Z.C6 2013 ___

_ ___ ___

C. College:

NAME OF SCHOOL LOCATION DATE OFYEAR

ATTENDANCEGRADUATED

N/AN/AN/AN/A ___
N/A N/AN/AN/A ___

D. Post Graduate:

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NAME OF SCHOOL LOCATION DATE OF YEAR

ATTENDANCEGRADUATED

N/A N/AN/AN/A ___

N/A N/AN/AN/A ___

E. Other Schools Attended and Date of Attendance:

Tesda San Roque Zamboanga City 2015 ___

N/A ___
N/A ___
N/A ___
(Signature of Applicant)

N/A ___

F. Civil Service eligibility/Date Acquired, if any and other Similar Qualifications Acquired:

N/A ___
N/A ___
N/A ___
N/A ___
N/A ___ ___

VI. MILITARY HISTORY:

A. Date Enlisted in the AFP: 23 February 2015 ___

B. Date of Commissionship: ___ ___
C. Source of Commission: ___ ___
D. Important Unit Assignment since Enlistment/CAD:
INCLUSIVE DATES UNIT/OFFICE CHIEF OF OFFICE
________________ ___ __ ___
________________ ___ __ ___

E. Military Schools Attended:

Schools/LocationDate Nature ofTraining Rating

Attendance
NCBde Seabees BTC 7 Months Basic Seaman Course __________

A. Decorations, Awards or Commendation Received:

Military Merit Medal _____________
Military Commendation Medal ________
(Signature of Applicant)

Military Civic Action Medal ______________________________________

The Anti-Dissidence Campaign Mecal and Ribbon ___
Award of SagisagngUlirangKawal ___

VII. PLACES OF RESINDENCE SINCE BIRTH:

Inclusive Dates Address
1994 to presentGov.RamosSta.Maria, Zamboanga City________________
___ ____________________________________________
___ ____________________________________________
___ ____________________________________________
___ ____________________________________________

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VIII. EMPLOYMENTS:
Inclusive DatesType of EmploymentName&Addressof Employer Reason for leaving
N/A N/A N/A N/A ___
N/A N/A N/A N/A ___
N/A N/A N/A N/A ___
N/A N/A N/A N/A ___

Have you ever dismissed or force to resign from a position? YES ( / ) NO ( / ) If yes,
explain? ___
___ ___
___ ___

IX. FOREIGN COUNTRIES VISITED:

DateCountryVisitedPurpose of VisitAddress Abroad
__________ _____________________________________________
___ _ __ ___
___ _ __ ___

X. CREDIT REPUTATION:
(Signature of Applicant)

A. Are you entirely dependent on your salary? Yes (/)No( ) If no, state other
source of income: ___
___ ___

B. Name and Address of Banks or other Credit Institution with which you have
accounts/Loans:PNSLAI/ ACDI / MBAI / PNFCCC ___
___ ___

C. Have you filed a statement of Assets and Liabilities with any government
agencies? Yes ( )No ( / )if so whatagencies? ___
___ ___

D. Have you filed your latest Income Tax Return ___

Amount Paid for the last Calendar Year? ___ ___

E. Three (3) Credit References in the Philippines:

Name Address
PNSLAINAVFORWEM, BagongCalarian, Zamboanga City _________
ACDI BagongCalarian, Zamboanga City _________
PNSLAINSJF, Bonifacio, Taguig City ___

XI. ARREST RECORDS AND CONDUCTS:

A. Have you ever been investigated/arrested, indicted or convicted for any violation
oflaw?YES ( ) NO ( / ) If so, state name of court, nature of offense and
disposition of case ___ ___
___
___

B. Has any member of your family have been investigated/arrested, indicted or

convicted for any violation of law? YES ( ) NO ( / ) If so, state name of court,
nature of offense and disposition of case ___ ___
___ ___
___

C. Have you been charge in any Administrative case? YES ( ) NO ( / ) If so,

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explain ___ ___

___
___

D. Have you been arrested or detained pursuant to the provision of PD 1081 and
implementing order (GO, SO, LOI? YES ( ) NO ( / ) If so, state nature of the case
and place of your detention

E. Do you use Intoxicating Liquor or Narcotics? YES ( ) NO ( / ) If so, what extent?

(Signature of Applicant)

XII. GENERAL REPUTATION:

A. Give Five (5) Character References (Known Three (3) years or longer who are
not your relative)

Name Address
1. Dennis DingalMaestraVicentaSta.Maira Zamboanga City
2. Tamier Raja Mango DriveSta.Maira Zamboanga City
3. Dwight Sta.TeresaSta.Maira Zamboanga City
4. RoselCagoSta.Maira Zamboanga City
5. Ryan BernabeSta.Maira Zamboanga City

B. List down three (3) neighbors at your present residence:

Name Address
1. LizelEstrellas Gov Ramos St.Sta.Maria,Zamboanga City
2. Milabel VillanuevaGov Ramos St.Sta.Maria,Zamboanga City
3. Beth Reyes Gov Ramos St.Sta.Maria,Zamboanga City
XII. ORGANIZATION:
C. List of organization or social groups which you have been member of:
ORGANIZATIONADDRESSDATE OF MEMBERSHIPPOSITION HELD

N/A N/A N/A N/A

N/A N/A N/A N/A
N/A N/A N/A N/A

XIII. MISCELLANEOUS:
D. Hobbies, sports, past time:

Playing Ball games/Playing Chess/ Watching TV Playing Guitar

E. Language and dialects spoken (Indicate as Fluent, Fair, Poor):

Language/Dialects/Speak/Read/Write
ChavacanoFluentFluent Fair
Tagalog FluentFluent Fluent
English FluentFluent Fair

F. Are you willing to undergo a periodic lie detector test? Yes

G. Copy the following paragraph in your own handwriting:

“As Luis E Repazo III of 105thXavier Ave. guzzled his way through three bottles of
brandy, Josephine Z Quinzing, a partner in the law firm of San Diego and Ballesteros

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located at 2879 Valley Forge St., Quezon City turned to Richard Ting Sr., a Chinese food
expert from O.W. Kwantung Company Ltd., 346 HadjiJairula Hussein Blvd., and said: “I
can’t speak for my government but I’m quite sure your country and mine better get
together for closer understanding”.

I certify that the foregoing answer are true and correct to the best of my knowledge
and belief and I agree that my misstatement or omission as to material fact will constitute
ground for immediate denial of my application for clearance.

Signed at HNFWM, NSRE, BagongCalarian Zamboanga City Date

______ ___________________________
(Witness) (Signature of Applicant)

______
(Witness)

THUMBMARKS

Left Right

SUBSCRIBED AND SWORN to before me this05day of Marchat O/NF2, NFWM,

NSRE BagongCalarian, Zamboanga City, Philippines, Affiant exhibited tome his/her
community Tax Certificate Nr.
Issued at Zamboanga city on

LESTER MARK C BAKY

MAJ PN(M)
AC of NFS for Intelligence, NF2
(Administering Officer)

Copy furnished:

1 – Security Officer
1 – Concerned Individuals

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