AIS Form B-2019 CONFIDENTIAL

APPLICANT’S INFORMATION SHEET

Please fill out form completely and legibly. Entries may be printed, typewritten or handwritten.

All items provided in this Information Sheet is classified CONFIDENTIAL and only for purposes of
protective security but subject to validation and investigation for purposes of conduct of Threat Assessment
and Complete Background Investigation. Any false, inaccurate or misleading information made by the
applicant herein may result to the denial of application or revocation of protective security.

I. PERSONAL DATA

COMPLETE NAME
Last Name:

First Name: Qualifier:

Middle Name:

DATE OF BIRTH: ____________________ PLACE OF BIRTH: ________________________________________

SEX: __________ CIVIL STATUS: _______________ RELIGION: _____________________________
NATIONALITY: _______________________________ BLOOD TYPE: ________
CITYADDRESS: _____________________________________________________________________________
PROVINCIAL ADDRESS: ______________________________________________________________________
CONTACT NUMBER/S: _________________________________________________________________
II. FAMILY BACKGROUND

NAME OF FATHER: _________________________________________________________________

CITIZENSHIP: ______________________________
MOTHER’S MAIDEN NAME: __________________________________________________________
CITIZENSHIP: ______________________________
NAME OF SPOUSE (Maiden name of wife): ______________________________________________
CITIZENSHIP: ______________________________
NAME OF CHILDREN: _______________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

III. PLACE/S OF RESIDENCE SINCE BIRTH

(Use separate sheet if necessary)
Complete Address Inclusive Year

IV. EDUCATIONAL BACKGROUND

(Use separate sheet if necessary)
Name of School Address Inclusive Year
Elementary

Secondary

CONFIDENTIAL
 AIS Form B-2019 CONFIDENTIAL
Tertiary

V. MEDICAL BACKGROUND
(Use separate sheet if necessary)
Physical and/or Medical Condition/History Medicine/s Being Taken Food or Medicine Allergies
(Please indicate particulars: i.e. Type 3 (Please indicate particulars)
diabetic, hypertension, suffered stroke, etc)

VI. EMPLOYMENT OR BUSINESS BACKGROUND

(If applicant is employed. Use separate sheet if necessary)
Name of Employer Address Position Year

(If applicant is self-employed or owns/co-owns business)

Name of Complete Address Nature of business
Company/Corporation

VII. COUNTRIES VISITED IN THE LAST FIVE YEARS

Country Year Reason for Visit

VIII. MEMBERSHIP IN CLUB/S OR ORGANIZATION/S

(Use separate sheet if necessary)

Name of Organization Position

IX.

CRIMINAL AND/OR DEROGATORY RECORDS

(Use separate sheet if necessary)
Title/Case Number and Branch of Status of Case Year Filed Details of Derogatory
Court Information

X. DETAILS ON THREAT
(Use separate sheet if necessary)

Source of Threat Cause of Threat Proof of Threat

CONFIDENTIAL
 AIS Form B-2019 CONFIDENTIAL
XI. BRIEF NARRATIVE OF INCIDENT/S RELATIVE TO THREAT/S
(Use separate sheet if necessary)
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
CERTIFICATION
I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED ABOVE ARE TRUE AND CORRECT TO THE
BEST OF MY KNOWLEDGE AND BELIEF.
_________________ ______________________
Date Accomplished Signature of Applicant

CONFIDENTIAL