CONFIDENTIAL

PERSONAL HISTORY STATEMENT

HPA FILE NR:

INSTRUCTIONS

1. ANSWER ALL QUESTIONS COMPLETELY. IF THE QUESTION IS NOT

APPLICABLE, WRITE “NA”. WRITE “UNKNOWN” ONLY IF YOU DO NOT KNOW THE

ANSWER AND CAN NOT OBTAIN FROM PERSONAL RECORDS. USE THE BLANK

PAGES AT THE BACK OF THIS FORM FOR EXTRA DETAILS OF THE ANSWERS TO

QUESTION FOR WHICH YOU DO NOT HAVE SUFFICIENT SPACE.

2. TYPE, PRINT OR WRITE CAREFULLY. ILLEGIBLE OR INCOMPLETE FORMS

WILL NOT RECEIVE CONSIDERATIONS.

WARNING

1. THE CORRECTNESS OF ALL STATEMENTS OR ENTRIES MADE HEREIN WILL

BE INVESTIGATED.

2. ANY DELIBERATE OMISSION OR DISTORTION OF MATERIAL FACTS MAY

GIVE SUFFICIENT CAUSE FOR DENIAL OF CLEARANCE.

3. THE STATEMENTS MADE HEREIN ARE CLASSIFIED CONFIDENTIAL.

REVELATION OR USE OTHER THAN THE AUTHORIZED PURPOSE IS PROHIBITED BY

AFPR G 200-053.

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 CONFIDENTIAL
I. PERSONAL DATA:

A. Name: ____________________________________________ ____

(Last) (First) (Middle/Maternal)
B. Rank: ___ AFPSN: AFOS / Br of Svc: _____
C. Present Assignment and Designation: _____
D. Job Title (If (Civilian): ______________ _____
E. Present Home Address: __________________________________________ _____
(Include Street and District)
F. Provincial Address: ________________________ _____
(Include Street and District)
G. Date of Birth: ______ Place of Birth: _________________ _____
H. Change in Name: (If court action, give details): _____
I. Nicknames: AFP ID Nr: _____
Religion: ______ TIN: ____________ ______ _____
Blood Type: ______ GSIS/SSS Nr: ____________ _____
Telephone Nr: Cell phone Number: ____________ _____

II. PERSONAL CHARACTERISTICS:

A. Description: Sex: Age: Height: ____ (meter)

Weight: (kgs) Built: (Heavy, Medium, Slight) _____
Complexion (Dark, Fair, Light): ______ Color of Eyes: ____
Color of Hair: __________
Scars or Marks and other distinguishing features: __________________

B. Physical Condition: Present State o Health: (Excellent, Good, Poor): __________

Physical or Mental Defects: _____
Recent Serious Illness: _____

III. MARITAL HISTORY:

A. Marital Status: _____

(Single, Married, Separated or Widowed)
B. Name of Spouse: __________________ _____
(Full Name)
Date of Marriage: ______ Spouse Date of Birth: __________
Spouse Place of Birth: ________ _____
Occupation and Place of Employment: _____
Citizenship: Filipino If naturalized, give date and place where naturalized: ____ ___
____
C. Children:

Name Date of Birth Address

(Use Separate Sheet for Additional Information)

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IV. FAMILY HISTORY AND INFORMATION:

A. Father: ____________________________________ _____

(Full Name)
Date of Birth: ________________ Place of Birth: ________ _____
Address: _____
(Include Street and District)
Occupation and Place of Employment: _____
Citizenship: __ If naturalized, give date and place where naturalized: _____

B. Mother: ________________________ _____

(Full Name)
Date/Place of Birth: __________________ _____
Address: _______________________ _____
Occupation / Place of Employment: _____
Citizenship: _____ If naturalized, give date and place where naturalized: _____

C. Brothers and Sisters:

Name Occupation Present Address

D. Step-Parent of Guardian: _____

(Full Name)
Address: _____
Date and Place of Birth: _____
Occupation and Place of Employment: _____

E. Father-in-Law: __________________ _____

Address: _____
Date and Place of Birth: ____________ _____
Occupation and Place of Employment: _____

F. Mother-in-Law: __________________ _____

Address: ________________________________________________ _____
Date and Place of Birth: ______ _____
Occupation/Place of Employment: _____

G. Brothers and Sisters-in-Law

Name Occupation Present Address

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V. EDUCATIONAL BACKGROUND:
A. Elementary
Name of School Location Date of Attendance

B. High School
Name of School
Name/Location of School Location
Date of Attendance Date of Attendance
Course /Year Graduated A. College

C. Post Graduate
__________________________ ________________ ___________________

D. Other Schools Attended

Name of School Location Date of Attendance
_____
E. Civil Service Eligibility, if any and other similar qualifications acquired: Professional -
passed

VI. MILITARY HISTORY:

A. Date Entered Mil Svc (as Trainee): _____
B. Date Enlisted: _____
C. Date Commissioned: _____
Source of Commission: _____
D. Date of CAD: _____
E. Have you ever been separated from the Military Service? _____
If yes, state nature and circumstances: _____
F. Important Duty Assignment:

Designation Inclusive Date Unit

_____

G. Military Schools/Training attended/undergone:

Name/Location of School Inclusive Dates Course

_____
_____
_____
(Use Separate Sheet for Additional Information)
H. Awards, Commendation or Decorations received:

Awards/Decorations/Commendations Authority
_____
_____
_____
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(Use Separate Sheet for Additional Information)
VII. PLACES OF RESIDENCE SINCE BIRTH:

Complete Address Inclusive Dates

___________________ ______________
___________________ ______________
___________________ ______________
___________________ ______________
VIII. EMPLOYMENT HISTORY:
__________________ ____________________
__________________ ____________________
__________________ ____________________
__________________ ____________________

Name/Address of Position Reason for Leaving Inclusive Dates

Employer
___________________ ______________ __________________ ____________________
___________________ ______________ __________________ ____________________
___________________ ______________ __________________ ____________________
___________________ ______________ __________________ ____________________

IX. FOREIGN COUNTRIES VISITED:

Date Countries Visited Purpose of Visit

___________________ ______________ __________________ ____________________
___________________ ______________ __________________ ____________________
X. CREDIT REPUTATION:

A. Are you entirely dependent on your salary? Yes _ ___ No _______________

If NO, state other source of income: _____ _____
B. Names and Addresses of Banks or other Credit Institutions with which you have
Accounts/Loans: _____________________________________________________
C. Have you filed a Statement of your Assets and Liabilities with any government agency?
Yes ___ No ____ If so, what agency? __________________________________ _
D. Three (3) Credit Reference in the Philippines:

Name of Person Complete Home Address

___ _________________________ __ _____________________________________
___ _______________________ __ ________________________________________
_________________________ __ _____________________________________
XI. ARTICLES OF WAR, CRIMINAL AND CIVIL RECORDS:

A. Have you ever been involved for any violation of the Articles of War, Revised Penal
Code (RPC), Civil Code and other Ordinances? Yes ___ No ___. If Yes, state name
of court, nature of offense, nature of involvement and disposition of case.
______________________________________________________________________
______________________________________________________________________

B. Has any member of your family been involved of any violation as stated in para A?
Yes ____ No __. If Yes, state name of court, nature of offense, nature of involvement
and disposition of case.
_____________________________________________________________________
______________________________________________________________________
C. Have you ever been charged in any administrative case? Yes ______ No __ .
If so, explain __ ________________________________________________________

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D. Have you ever been arrested or detained pursuant to PD 1081 and its implementing
orders (GO, PO, LOI)? Yes _____ No __ . If so, state the name of court, nature
of offense and place of detention.___
__________________________________________
______________________________________________________________________

E. Do you use/drink intoxicating liquor/beer? Yes ____ No _____. If so, to what extent?
___________________________________________________________________
F. Do you use drugs or narcotics? Yes _____ No __ . If so, specify and to what
extent? _____________________________________________________________

XII. GENERAL REPUTATION:

A. Give five (5) character references (Known three (3) years or longer who are not your
relatives):
Full Name Complete Home Address
________________________________ _______________________________________
________________________________ _______________________________________
________________________________ _______________________________________
________________________________ _______________________________________
________________________________ _______________________________________

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

Full Name Complete Home Address

________________________________ _______________________________________
________________________________ _______________________________________
________________________________ _______________________________________

XIII. ORGANIZATIONS:
List of organizations or social groups which you have been a member of:
Name of Organization Position Held Date of Membership
__________________________________ ______________ ________________________
__________________________________ ______________ ________________________
__________________________________ ______________ ________________________

XIV. MISCELLANEOUS:

A. Hobbies, Sports and Past Times:

_____________________________________________________________ _____

B. Skills (such as driving, carpentry, shorthand, typing, designing, etc)

__________________________ ________________________________________

C. Languages/Dialects Spoken (Indicate ability as Fluent/Fair/Poor)

Language or Dialect Speak Read Write
____ ______________________ __ _____ ________ __ _____
____ ______________________ __ _____ ________ __ _____
____ ______________________ __ _____ ________ __ _____
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D. Are you willing to undergo periodic lie detector test? Yes ________ No __________

E. Copy exactly the following paragraph in your own handwriting:

As Luis Repaso III of 105th Xavier Ave., guzzled his way through three bottles of brandy,
Josephine Z Quinzing, a partner in the law firm of San Diego and Ballesteros located at 2679 Valley
Forge St., Quezon City turned to Richard Ting Sr., a Chinese Food Expert from O.W. Ewaman
Company Ltd., 346 Hadji Hairula Hussein Blvd., and said “I can’t speak for my government, but I’m
quite sure your country and mine will get together for closer understanding”
___________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________ _____
_________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________ _____
_________________________________________________________________________________

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

Signed at __________________________________________ Date ___________________

WITNESSES: __________________________________
(Signature of Applicant)
______________________________________
______________________________________

2X2
LEFT HAND RIGHT HAND
PICTURE
THUMB MARK THUMB MARK

SUBSCRIBED AND SWORN to before me this ________ day of

_______________20________ at ______________________________________________________,
Philippines. Affiant exhibiting to me his/her Residence Certificate Nr ___________________ issued on
____________20_____ at ________________________________________________________

_________________________________________
(Administering Officer)
________________________________________
(Designation)

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TIN: ___________________________

SKETCH OF THE IMMEDIATE VICINITY OF RESIDENCE

(Indicate Prominent Points/References)

CONFIDENTIAL
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