CONFIDENTIAL

ANNEX A of AFPR G 200-054 dtd 22 September 2014;

GHQ J2 File Nr
200-054 Form
PERSONAL HISTORY STATEMENT

INSTRUCTIONS

1. Answer all questions completely; if question is not applicable, write “NA”. Write
“UNKNOWN” only if do not know the answer and cannot obtain the answer from personal
records. Use the blank pages at the back of this form for extra details on any question for which
you do not have sufficient space.

2. Type, print or write carefully, illegible or incomplete forms will not receive
consideration.

WARNING

1. The correctness of all statements of entries made herein will be investigated.

2. Any deliberate omission or distortion of material facts is a sufficient ground for

denial clearance.

3. The statement made herein is classified CONFIDENTIAL. Revelation or use

other than the authorized purpose is prohibited by AFPR G 200-054.

I. PERSONAL DETAILS
A. Name:

(Last) (First) (Middle/Maternal)

B. Rank: AFPSN: Br of Svc:
C. Present Job/Assignment:
D. Business or Duty Address:
E. Home Address (Include Street & No.)

F. Birth date:___ Place:

G. Change in Name (If by Court Action give details):

_________________________________________________________________

H. Nicknames: Nationality:_________________________________

I. Tax Identification Nr: _________ Telephone Nr:

J. Mobile Phone Nr: ______________E-Mail Address: _________________

K. Passport Nr. ______________________ Date of Expiration: __________________

CONFIDENTIAL
 CONFIDENTIAL

ANNEX A of AFPR G 200-054 dtd 22 September 2014;

II. PERSONAL CHARACTERISTICS

A. Description: Sex: Age: Height: Weight:

Build: (Heavy, Medium, Light): (Dark, Fair, Light):
Color of Eyes:
Color of Hair:
Scars or Marks and other distinguishing features:

B. Physical Condition
Present State of Health (Excellent, good, poor):
Physical or Mental Defects:
Recent Serious Illness:

III. FAMILY HISTORY AND INFORMATION

A. Father:
(Full Name)
Date and Place of Birth:
Address:
Occupation and Place of Employment:
Citizenship:
If naturalized, give date and place where naturalized:
B. Mother:
(Full Name)
Date and Place of Birth:
Address:
Occupation and Place of Employment:
Citizenship:
If naturalized, give date and place where naturalized:

C. Brothers and Sisters:

Name Age Address Occupation

D. Step-Parent or Guardian:
Address:
Occupation and Place of Employment:
Citizenship:
If naturalized, give date and place where naturalized:

IV. MARITAL HISTORY

A. Marital Status:
(Single, Married, Separated or Widow)
B. Name of Spouse:

CONFIDENTIAL
 CONFIDENTIAL

(Full Name)
Date and Place of Marriage:

Occupation and Place of Work:

C. Children:

Name DOB/Citizenship Address

D. Father-In-Law:
Date and Place of Birth:
Address: Tel. No.:
Occupation and Place of Employment:
Citizenship:
If naturalized, give date and place where naturalized:

E. Mother-In-Law:
F. Date and Place of Birth:
Address: Tel. No.:
Occupation and Place of Employment:
Citizenship:
If naturalized, give date and place where naturalized:

V. EDUCATIONAL BACKGROUND

A. Elementary Location Yr Graduated Course Finished

B. High School

C. College

D. Other Schools attended and Dates of Attendance

E. Civil Service eligibility, if any and other similar qualifications acquired

VI. MILITARY HISTORY

A. Date entered/Enlisted in the Military Service/AFP

CONFIDENTIAL
 CONFIDENTIAL

(Include Training/Draftee or Cadetship):

B. Date of Commission:
Source of Commission:

C. Important Unit Assignments since Trng/Date, Enlistment’s, Probationary,

CAD, Commission ship:

Designation Unit/Office

D. Military Schools Attended: (Use other sheet of paper if needed)

Name of Schools & Location Period Attended Nature of Trng

E. Decorations, Awards or Commendations Received: (Use other sheet

of paper if needed)

AWARDS & DECORATION DATE AWARDED AUTHORITY

VII. PLACES OF RESIDENCE SINCE BIRTH

Place/Address Inclusive Dates

VIII. EMPLOYMENT

Type of Inclusive Name & Address Reason

Employment Dates of Employer for Leaving

Have you ever been dismissed or forced to resign from a position?

CONFIDENTIAL
 CONFIDENTIAL

ANNEX A of AFPR G 200-054 dtd 22 September 2014, con’t;

IX. FOREIGN COUNTRIES VISITED

Date of Visit Country Visited Purpose of Visit Address Abroad
__________________ __________________ ______________ _____________
__________________ __________________ ______________ _____________
__________________ __________________ ______________ _____________
__________________ __________________ ______________ _____________
__________________ __________________ ______________ _____________

X. CREDIT REPUTATION

A. Are you entirely dependent on your salary? Yes ( ) No ( ) if no state source of

income:
____________________________________________________________________

B. Names and address 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 ( ) ____________________________________________________
______________________________________________________________________

D. Have you filed your latest Income Tax Returns? __________________________

Amount paid for the last Calendar Year. ________________________________

E. Three (3) credit references in the Philippines:

Name
___________________________________
___________________________________
___________________________________
___________________________________
Address
__________________________________________
___________________________________________
___________________________________________
___________________________________________

XI. ARREST AND CONDUCT

A. Have you ever 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.

______________________________________________________________________

B. Has any member of your immediate family 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.

______________________________________________________________________

CONFIDENTIAL
 CONFIDENTIAL

ANNEX A of AFPR G 200-054 dtd 22 September 2014, con’t;

C. Have you ever been charge of any administrative case? Yes ( ) if so, explain:

D. Have you ever been arrested or detained pursuant to the provisions of PD 1081 and its
implementing orders (GO, PD, LOI)? Yes ( ) No ( ) If so, state the nature of the case and the
place of your detention. _________________________________________
______________________________________________________________________

E. Do you use intoxicating liquor or illegal drugs? Yes ( ) No ( ) If so, to what extent?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

XII. GENERAL REPUTATION:

A. Give five (5) character references (known three years or longer, who are not your relatives):

Name Address
___________________________________ __________________________________________
___________________________________ ___________________________________________
___________________________________ ___________________________________________
___________________________________ ___________________________________________
___________________________________ ____________________________________________
___________________________________ ____________________________________________

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

Name
___________________________________
___________________________________
___________________________________
___________________________________
Address
__________________________________________
___________________________________________
___________________________________________
___________________________________________

XIII. ORGANIZATIONS:

C. List of organizations or social groups which you have been a member of

Organization Address Date of Position

Membership Held
______________ _____________________ _________________ _____________________

______________ _____________________ _________________ _____________________

______________ _____________________ _________________ _____________________

______________ _____________________ _________________ _____________________

______________ _____________________ _________________ _____________________

CONFIDENTIAL
 CONFIDENTIAL

ANNEX A of AFPR G 200-054 dtd 22 September 2014, con’t;

XIV. MISCELLANEOUS:

D. Hobbies, sports and past times:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______

E. Language and Dialect (indicated ability as fluent, fair or poor)

Language/Dialect Speak Read Write

______________ _________________ ____________ _______________________
______________ _________________ ____________ _______________________
______________ _________________ ____________ _______________________
______________ _________________ ____________ _______________________

F. Are you willing to undergo periodic lie detection test? _________________

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

As Luis E Repazo III of 105 th Xavier Ave guzzled his way through three
bottles of brandy, Josephine Z. Quinsing 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 Hairul 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”.

_____________

ANNEX A of AFPR G 200-054 dtd 22 September 2014, con’t;

CONFIDENTIAL
 CONFIDENTIAL

I certify that the following answers are true and correct to the best of my
knowledge and belief and I agree that my miss statement or omission as to material
facts will constitute ground for denial of my application for clearance.

Signed at Date

(Signature of Applicant)

(Witness)

(Witness)

THUMB MARKS:
2x2 Photo

(Left) (Right)

SUBSCRIBED AND SWORN to before me this day of

Philippines, affiant exhibited to me his/her Community Tax Certificate Nr.
Issued at on .

_____________________________

_____________________________

_____________________________
(Administering Officer)

ANNEX A of AFPR G 200-054 dtd 22 September 2014, cont’n;

CONFIDENTIAL
 CONFIDENTIAL

SKETCH OF THE IMMEDIATE VICINITY OF RESIDENCE

CONFIDENTIAL
 CONFIDENTIAL

ABC Form 1

PERSONAL IDENTIFICATION NR: Control Nr:

Name: Photo Nr:
Address: Classification:
Color: Sex: Reference Classification:

RIGHT HAND

1. Thumb 2.Index Finger 3.Middle Finger 4. Ring Finger 5.Small Finger

LEFT HAND

1. Thumb 2.Index Finger 3.Middle Finger 4.Ring Finger 5.Small Finger

Impression Taken by:

Signature of individual taking prints (Subject)

(Left Hand) (Right Hand)

Four Fingers Left Thumb Right Thumb Four Fingers

CONFIDENTIAL