ANNEX A of AFPR G 200-054 dtd 28 May 2019 SHO Oe File Nr i PERSONNEL HISTORY STATEMENT i , INSTRUCTIONS 1. Answer all questions completely, if question is not applicable, wrte NA’ Write "UNKNOWN" only if you 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 vou do not have suflicient space, 2 Type, print or write carefully legible or icompletefortns will not rsceive consideration 1. The correctness of all statements of entries made herein will be invest gated 3 2 Any deliberate omission or distortion of material facts nay give sufficient cause for denial of | clearance. 3. ___ The statements made herein are classified CONFIDENTIAL. Revelation of use other than E the authorized purpose is prohibited by AFPR G 200.054, | | WARNING |. PERSONAL DETAILS | ROONAME E Cast) First) (WiddiemMtatema i B. RANK: AFPSN. BRISVC . : C. PRESENT JOB/ASSIGNMENT: ___ = 3 D. — BUSINESSOR DUTY ADDRESS: __ i E. HOME ADDRESS (Include street & number): _ _ __. F. BIRTHDATE: __ PLACE: t G. CHANGE IN NAME (ff by Court Action, give details): H. NICKNAMES: ___ NATIONALITY: |. TAK IDENTIFICATION NR: TELNO J. MOBILE PHONE NR: _ E-MAIL ADDRES': K. PASSPORTNR:____ _ DATE OF EXPIRATION __ ‘Gignature of Applicant Scanned with CamScannerANNEX A of AFPR G 200-054 dtd 28 May 2019 cont'n: ll, PERSONAL CHARACTERISTICS: A. DESCRIPTION: Sex____Age__._ Height_(M) Weight Build (Heavy, Medium, Light) ! Complexion (Dark, Fai, Light): __ Color of Har. Scats or Marks & Other Distinguishing Features, __ B. PHYSICAL CONDITION Present State of Health (Excellent, good, Poor): __| Recent Serious Illness: _ Blood Type: __ UL MARITAL HISTORY A. MARITAL STATUS: __ ee: ‘ingle, Married, Separated or Wi lowed) B. NAMEOF SPOUSE: __ i lame) 7 Date & Place of Marriage Date of Birth: _ Place of Birth: Occupation & Place of Employment: Contact Number: Citizenship: —ifdual, (Other Citizenship) C. CHILDREN: Name Date of Birth _—_Citizenship/Address__ Name of Father/Mother (Use back page lor additional information) e 8 ZIV. FAMILY HISTORY AND INFORMATION: S 2 A FATHER: ee a Ag ig (Fail Namey 5 Date & Place of Birth o, N ‘Scanned with CamScannerANNEX A of AFPR G 200-054 dtd 28 May 2019 cont'n: Complete Address: Citizenship: I dual. write both citizenship. If naturalized, give date and place where naturalized MOTHER: ee a (Fall Namey Date & Place of Birth _ Complete Address: Occupation/Employer/Place of Employment: _ a Citizenship: __ l¥dual, write both citidenship. If naturalized, gve dat and place where naturalized. BROTHERS AND SISTERS: DATE OF BIRTH ‘(Signature of Applicant) STEP-PARENT OR GUARDIAN: _ (Full Namie) Date & place of Birth __ Complete Address: Occupation/Employer/Place of Employment: Citizenship: _ dual write both citizenship. f naturalized, give date ‘and place where naturalized FATHER-IN-LAW: (Full Namey Date & Place of Birth _ Complete Address: _ Occupation/Employer/Place of Employn: Citizenship: dual, write both citizenship. If naturalized, give date ‘and place where naturalized, GONFig ITIAb Scanned with CamScanner ee —— a i a‘Signature of Applicant) ANNEX A of AFPR G 200-054 dtd 28 May 2019 cont'n F. MOTHER. IN-LAW: _—— SS (Full Name) Date & Place of Birth Complete Address: ‘Occupation/Employer/Place of Employment _ if dual, wnite both citizenship. If naturalized, give date and place where naturalized EDUCATIONAL BACKGROUND A. Elementary Location [Date of Yea | ‘Attendance Graduated —— B. High Schoo! Location Date of Year Atondance Graduated B. College Location Date of Course Taken’ Attendance Year Graduated C. Post Graduate Location Date of Course Taken! Attendance Year Graduated E. Other Schools/Tvaining Attended anc! Date of Attendance: Scanned with CamScanner‘Gignature of Applicant) ANNEX A of AFPR G 200-054 dtd 28 May 2019 cont’ Vi. MILITARY HISTORY: Date Enlisted in the AFP A B. Date of Commission: ©. ‘Source of Commission: _- D. __ Important Unit Assignments since EniisbnentCAU: INCLUSIVE DATES: UNITIOFFICE E. Military Schools Attended ‘School/Location Date of Nature of Rating Training Scanned with CamScannerlevee tele flit (Use adaitonal sheeisW necessary) Vil. PLACES OF RESIDENCE SINCE BIRTH: Inclusive Dates Addters Litt trig | Vill. EMPLOYMENT: Inclusive Type of Name & Address Reason for Date Employment ‘of Employer Leaving tid Have you ever been dismissed or forced to resign liom a position: No) Yes ) I yes, explain le = : § a = a JZ 1X. FOREIGN COUNTRIES VISITED: 5 @ Date of Visit Country Visited Purpose of Visit, 2 2 je — ONFIDE! fas. Scanned with CamScanner‘(Signature of Applicant ANNEX A of AFPR G 200-054 dtd 28 May 2019 cont’ X. GREDIT REPUTATION: ‘Ate you entirely dependent on your salary? Yes ( ) No ( ) if no state other sources of income: nn as B. Name and address of banks or other credit institutions. with winch you have accounts/loans _ - ©. Have you filed statement of your Assets and Yes) No( ) If'so, what Agency? D. Have you filed your latest Income Tax Retuns? __| ‘Amount paid for the last Calendar Year E.__ Thee (3) credit references in the Philippines: Name Address | Xl ARREST RECORD AND CONDUCT: A. Have you ever been investigated/arrested, indicted qr convicted for any wolation of taw? Yes () No( ). If so, state name of court, nature of offense and dispopition of case. B. _Has any member of your family been investigated/arrested, indicted or conwcted for any Violation of law? Yes( ) No ). If so, state name of court, nature of offense and disposition of case __ C. Have you ever been chaiged of any administrative case? Yes () No( ) iso explain _ D. Have you eve’ been arrested or dotained pursuant to the provisions of PD 1081 and its implementing orders (GO, PD, LO!)? Yes( ) No ( 1 Ifso, state the nature of the case and the place of your detention. XU GENERAL REPUTATION: A. Give five (6) character references (known three years or longer, wie are not your relatives) Name Address, y ETAL Scanned with CamScannerANNEX A of AFPR G 200-054 dtd 28 May 2019 cont'n: B. List down three (3) neighbors at your present residence. Name Address XII ORGANIZATIONS: C. List of organizations or social groups which you have been a memhet of Qraanization Address Postion Held XIV. MISCELLANEOUS: D. Hobbies, sports and past times. E Language and cialects (indicate ability as fluent, fair or poor} Lanquage/Dialect Speak Read White F. Are you willing to undergo periodic lie detector test? G. Copy exactly the following paragraph in your own handwriting, As Luis E Rapazo Ill of 105” Xavier Ave uzzled his way through three bottles of brandy, sosephine Z Quinsing, a partner in the law firm of San Diewo and Ballesteros located at 2879 Valley Farge & St, Quezon City tumed to Richard Ting St, a Chinese foc! expert from O.WW. Kwantung Company Li 326 § Hag Jaiula Hussein Biv, and said: | cart speak for my government but 'm quits sue your country ane mine better get together for closer understanding.” (Signature of Appi Scanned with CamScannerANNEX A of AFPR G 200.054 dtd 28 May 2019 cont'n: | certify that the foregoing answers are true and correct to the best of my knowledge and belief and | agree that any misstatement or omission as to a material fact will constitute ground for immediate denial of my application for clearance. Signed at _ Date Be (Winessy —_ — (Witness) ~~ THuMe MARKS | | Right) SUBSCRIBED AND SWORN to before me this. Philippines, Affiant exhibited to me his/her Community Tax Certificate Nr oo issued at. on Scanned with CamScannerANNEX A of AFPR G 200-054 dtd 28 May 2019 cont'n; SKETCH YOUR RESIDENGE ADDRESS (Signature of Applicant) Scanned with CamScannerANNEX B of AFPR G 200 - 054 REPUBLIC OF THE PHILIPPINI DEPARTMENT OF NATIONAL DEF GENERAL HEADQUARTERS, ARMED FORCES "2 Camp General Emilio f.guinaido, Qu HE PHLIPPINES SECURITY DECLARATICN (To be read and signed by all miltary personnel, employees and reo2arch contact I ol legal age. (employed. @ of do hereby declare or affirm 1. That I shall be responsible for presewvinig the secuniy ¢ all Uaseified ir be imparted to me as a result of my employmentiraininglresearch witn the Armed '¢ os & and undertake to comply with such regulations concerning security us may from tin: te Ge 2. That I shall not divulge any classified informe’ employmentitraining/research to any unauthorized person, either in ed by me wt Cee 3. That I shall not, without authority of the Chief of Ste or in the future , publish any classified information which | have scquire ‘owing to my employmentitraining/research in the ab any document, article, book, play, film or othenwise; H i 4, That on leaving the 1 shelligunendar : article, note, security tag/badge or document, hard oF soft copy, made c, acquire by Official dutiestraininglresearch, declared to be classified matezialinfoymation. se~v2 such = 1 = duly authorized to retain by the 5. That failure on my part to safeguard classified isformation can make me security clearance to prosecution under the Revised Penal Code and Conierwnal” 3. declared as security risk. U hereby certify that | have read and fully understood AFPR © 200414 and: 2 Responsibilities of safeguarding Armed Forces classified information, | fully understand that the provisions of this Security Dectatation ¢j my employmentftaining/research, but also after my employment?rainingiteszare* ‘ceased, that | am liable to prosecution under the Revised Adri other existing laws, regulations of the Republic of the Piuiein: classified information to pass into unauthorized hancls ‘SUBSCRIBED AND SWORN TO BEFORE ME GNI THIS DAYOF. 2 Copy fu 1 ~ Security Officer 2 Concemed Individual Scanned with CamScanner