CONFIDENTIAL

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

GHQ, OJ2 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 you
do not know the answer 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 of clearance.

3. The statements made herein are 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/SVC:__________________________________________

______________________
(Signature of Applicant)
C. PRESENT JOB/ASSIGNMENT: _________________________________________________________

D. BUSINESS OR DUTY ADDRESS: _______________________________________________________

E. HOME ADDRESS (Include street & number): _______________________________________________

___________________________________________________________________________________

F. BIRTHDATE: _________________ PLACE: _______________________________________________

G. CHANGE IN NAME (If by court Action, give details): _________________________________________

___________________________________________________________________________________

H. NICKNAMES: ___________________________ NATIONALITY: _______________________________

I. TAX IDENTIFICATION NR: ______________________ TEL NO. _______________________________

J. MOBILE PHONE NR: __________________________ E -MAIL ADDRESS: ______________________

K. PASSPORT NR: __________________________ DATE OF EXPIRATION: ______________________

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

II PERSONAL CHARACTERISTICS:

A. DESCRIPTION; Sex: _________Age: __________Height: ____________ (M) Weight: ____________(kgs)

Build (Heavy, Medium, Light):_____________________________________________________________

Complexion (Dark, Fair, Light): _____________________________ Color of Eyes: ___________________

Color of Hair: ________________________ Scars or Marks & other Distinguishing Features: ___________
_____________________________________________________________________________________

B. PHYSICAL CONDITION:

Present State of Health (Excellent, good, Poor): ______________________________________________

Recent Serious illness: __________________________________________________________________

Blood Type: ____________

III. MARITAL HISTORY

A. MARITAL STATUS: ____________________________________________________________________

(Single, Married, Separated or widowed)

B. NAME OF SPOUSE: ___________________________________________________________________

(Full Name)

Date & Place of Marriage: _______________________________________________________________

______________________
(Signature of Applicant)
Date of Birth: _____________________________ Place of Birth: ________________________________

Occupation/Employer/Place of Employment: _________________________________________________

_____________________________________________________________________________________

Contact Number: _________________ Citizenship: ______________ If dual, _______________________

(Other citizenship)

C. CHILDREN:

Name Date of Birth Citizenship/Address Name of Father/Mother

__________________ ________________ ______________________ ________________________

__________________ ________________ ______________________ ________________________
__________________ ________________ ______________________ ________________________
__________________ ________________ ______________________ ________________________
__________________ ________________ ______________________ ________________________

(Use back page for additional information)

IV. FAMILY HISTORY AND INFORMATION:

A. FATHER: ______________________________________________________________________
(Full Name)
Date & Place of Birth: _____________________________________________________________

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

Complete Address: ________________________________________________________________________

Occupation/Employer/Place of Employment: ____________________________________________________

Citizenship: _________________________ If dual, write both citizenships. If naturalized, give date and place
where naturalized: ________________________________________________________________________

B. MOTHER: ________________________________________________________________________________
(Full Name)
Date & Place of Birth: _______________________________________________________________________

Complete Address: _________________________________________________________________________

Occupation/Employer/Place of Employment: ____________________________________________________

Citizenship: _________________________ If dual, write both citizenships. If naturalized, give date and place
where naturalized: ______________________________________________________________________________

C. BROTHERS AND SISTERS:

NAME DATE OF CITIZENSHIP (IF COMPLETE OCCUPATION EMPLOYER/ADDRESS

BIRTH DUAL, WRITE ADDRESS
BOTH)

D. STEP- PARENT OR GUARDIAN: _______________________________________________________________

(Full Name)
Date & Place of Birth: ________________________________________________________________________

Complete Address: __________________________________________________________________________

Occupation/Employer/Place of Employment: ______________________________________________________

Citizenship: _________________________ If dual, write both citizenships. If naturalized, give date and place
where naturalized: ________________________________________________________________________________

______________________
E. FATHER -IN -LAW: __________________________________________________________________________
(Signature of Applicant) (Full Name)
Date & Place of Birth: ________________________________________________________________________

Complete Address: ___________________________________________________________________________

Occupation/Employer/Place of Employment: ______________________________________________________

Citizenship: _________________________ If dual, write both citizenships. If naturalized, give date and place
where naturalized: __________________________________________________________________________

F. MOTHER -IN -LAW; _________________________________________________________________________

(Full Name)
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ANNEX A of AFPR G 200-054 dtd 22 September 2014, cont ‘n;

Date & Place of Birth: ________________________________________________________________

Complete Address: __________________________________________________________________

Occupation/Employer/Place of Employment; ______________________________________________

Citizenship: __________________________________________ If dual, write both citizenship. If

naturalized, give date and place where naturalized: ________________________________________

V. EDUCATIONAL BACKGROUND

A. Elementary Location Date of Year

Attendance Graduated

___________________________ ______________________ ______________________ __________________

___________________________ ________________________ _____________________ __________________
___________________________ ________________________ ______________________ _________________
___________________________ ________________________ ______________________ _________________

B. High School Location Date of Year

Attendance Graduated

________________________ ______________________ _______________ __________________

_________________________ ______________________ _______________ __________________
________________________ _____________________ _______________ __________________

C. College Location Date of Course Taken/

Attendance Year Graduated

_____________________ _____________________ ______________________ _______________________

_____________________ ______________________ ______________________ ______________________
_____________________ _____________________ ______________________ _______________________

D. Post Graduate Location Date of Course Taken/

______________________
(Signature of Applicant)
___________________________ ______________________
___________________________ ______________________
___________________________ ______________________
Attendance Year Graduated
______________________ ________________
______________________ ________________
______________________ ________________

E. Other Schools/Training Attended and Date of Attendance:

________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

F. Civil Service Eligibility/Date Acquired, if any, and Other Similar Qualifications Acquired:

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

IV. MILITARY HISTORY:

A. Date Enlisted in the AFP: _______________________________________________________________

B. Date of commission: ___________________________________________________________________

C. Source of Commission: _________________________________________________________________

D. Important Unit Assignments since Enlistment/CAD:

INCLUSIVEDATES UNIT/OFFICE CHIEF OF OFFICE

________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
______________________
________________________________________________________________________________________________
(Signature of Applicant)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

E. Military Schools Attended:

School/Location Date of Nature of

Attendance Training Rating

_____________________________ _________________________ ________________ _______________

_____________________________ ________________________ ________________ _______________
_____________________________ _________________________ _______________ _______________
______________________________ _________________________ ________________ _______________
______________________________ __________________________ ________________ _______________
______________________________ _________________________ ________________ _______________
_____________________________ _________________________ _______________ _______________
______________________________ __________________________ _______________ _______________
_____________________________ __________________________ ________________ _______________
_____________________________ __________________________ ________________ _______________
_____________________________ _________________________ _______________ _______________
_____________________________ _________________________ ________________ _______________
_____________________________ ________________________ ________________ _______________
_____________________________ _________________________ ________________ _______________
_____________________________ _________________________ ________________ _______________

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

F. Decoration, Award or Commendations Received:

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
(Use additional sheets if necessary)

VII. PLACES OF RESIDENCE SINCE BIRTH:

Inclusive Dates Address

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
_______________________________________________________
_______________________________________________________
______________________________________________________
_______________________________________________________
_______________________________________________________
________________________________________________________
_______________________________________________________

VIII. EMPLOYMENT:
______________________
(Signature of Applicant)
Inclusive Type of Name & Address Reason for
Date Employment of Employer Leaving
_____________________ _________________ _____________________ ______________________
_____________________ __________________ ______________________ ______________________
_____________________ __________________ _____________________ ______________________
____________________ __________________ ____________________ ______________________
___________________ __________________ ____________________ ______________________
__________________ __________________ ____________________ ______________________

Have you ever been dismissed or forced to resign from a position: No ( ) Yes ( ) if yes, explain

________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

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

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 other sources of income:
____________________________________________________________________________________________________________

B. Name 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 ( ) if so What Agency and when ? _________________________________________________________________

___________________________________________________________________________________________________________

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

Amount paid for the Last Calendar Year: _______________________________________________________

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

______________________
(Signature of Applicant)Name Address

___________________________________________ _____________________________________________________________
___________________________________________ _____________________________________________________________
___________________________________________ _____________________________________________________________
___________________________________________ _____________________________________________________________

XI. ARREST RECORD AND CONDUCT

A. Have you ever been investigated/arrested, indicated 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, indicate or convicted for any
violation of law? Yes ( ) No ( ). If so , state name of court, nature of offense and disposition of case.
________________________________________________________________________________________________
________________________________________________________________________________________________

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

C. Have you ever been charged of any administrative case? Yes ( ) No ( ) 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 o9f 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
__________________________________ ________________________________________________
__________________________________ ________________________________________________
__________________________________
______________________ ________________________________________________
(Signature of Applicant)

XIII. ORGANIZATIONS:

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

Organization Address Date of Position

Membership Held

_____________________________ _________________________ _________________________ _________________

_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________
_________________
_________________
_________________
_________________

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

XIV. MISCELLANEOUS:

D. Hobbies, sports and past times.

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

E. Language and Dialects (indicate ability as fluent, fair or poor):

Language/Dialect Speak Read Write

___________________ _________________________ _________________________ _________________

___________________ _________________________ _________________________ _________________
___________________ _________________________ _________________________ _________________
___________________ _________________________ _________________________ _________________

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

_____________________________________________________

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

As Luis E Rapazo III of 105th Xavier Ave. guzzled his way trough three bottles of brandy. Josephine Z
Quinsing, a partner in the law firm of San Diego and Ballesteros located at 2879 Valley Forge St., Quezon City turned to
Richard Ting Sr., a Chinese food expert from O.W. Kwantung Ltd., 346 Hadji Jairula Hussein Blvd., and said: :I can’t
speak for my government but I’m quiet sure your country and mine better get together for closer understanding.”

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
______________________
(Signature of Applicant)

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

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

Signed at ______________________________________________ Date _____________________

_______________________
_____________________________
(Witness)
(Signature of applicant)

2x2 Photo
_______________________
(Witness)

THUMB MARKS:

(Left) (Right)

SUBSCRIBED AND SWORN to before me this __________ of ___________________________________

Philippines, Affiant exhibit to me his /her Community Tax Certificate Nr _______________________________________
issued at: ______________________________ on _____________________________________.

_______________________________

_______________________________

_______________________________
(Administering Officer)

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

SKETCH OF THE LOCATION OF RESIDENCE

______________________
(Signature of Applicant)

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