DATA CAPTURED FORM

2X2 PXCS
BASIC INFORMATION

*FULL NAME:
LAST NAME FIRST NAME MIDDLE NAME
*AFP SERIAL NUMBER: *BOS:
*LAST NAME: *FIRST NAME:
*MIDDLE NAME: EXTENSION NAME:
NICK NAME: *RANK:
*CATEGORY; *STATUS:
*OFFICE ASSIGNMENT:
*DESIGNATION: *CLASSIFICATION:
*GENDER:
*AUTHORITY:
SO/GO NR UNIT DATE
*CIVIL STATUS: *CITIZENSHIP:
*BIRTHDATE: IDENTIFICATION MARK:
*BIRTHPLACE: ETHNIC GROUP:
*RELIGION: *BLOOD TYPE:
BODY BUILT: *HEIGHT: (ft./m) *WEIGHT: (kg)
*EYE COLOR: *HAIR COLOR: ______________________

 IF MARRIED
SPOUSE INFORMATION

*NAME:
*CONTACT NUMBER: *DATE OF BIRTH:
*DATE OF MARRIAGE: *OCCUPATION:
EMAIL ADDRESS: *PLACE OF BIRTH:
*PLACE OF MARRIAGE:
*ADDRESS:

FAMILY BACKGROUND:
DEPENDENTS:
NAME B-DAY RELATIONSHIP ADDRESS

PRESENT ADRESS:

*HOUSE NUMBER: *STREET:

*SUBDIVISION: *BRGY:
*TOWN: *CITY:
*ZIP CODE:
PREVIOUS ADDRESS:

HOUSE NUMBER: STREET:

SUBDIVISION: BRGY:
TOWN: CITY:
ZIP CODE:

CONTACTS:

LANDLINE #: *MOBILE # 1:
MOBILE #2: *EMAIL ADD:

CONTACT PERSON:

*CONTACT NAME:
*ADDRESS:
*RELATION: *MOBILE #:
EMAIL ADD:

ID CARD:

*TIN #: *GSIS #:
*PAG- IBIG #: *PHILHEALTH #:
*SSS #:

TARRIF SIZES:
COMBAT BOOTS: BDU: CAP:
T-SHIRT: SHORT: DRESS SHOES

SOURCE OF ENLISMENT:
*AUTHORITY:
SO/GO NR UNIT DATE

STATEMENT OF SERVICE:

ASSIGNMENT/ REASSIGNMENT:
*RESERVIST COMPONENT:
*UNIT ASSIGNMENT:
*MOBILIZATION CENTER:
*TYPE: *POSITION:
DATE FROM: DATE TO:
*AUTHORITY:
SO/GO NR UNIT DATE

PROMOTION:
*RANK: *RANK STATUS:
DATE FROM: DATE TO:
*AUTHORITY:
SO/GO NR UNIT DATE
ACTIVE SERVICE:
*TYPE: PURPOSE:
*AUTHORITY:
SO/GO NR UNIT DATE

EDUCATIONAL BACKGROUND:

CIVILIAN SCHOOLING:
EDUC LEVEL COURSE SCHOOL NAME DATE GRADUATED
PRIMARY

SECONDARY

TERTIARY

BOARD ELIGIBILITY:

*TYPE OF LICENSE:
DATE OF EXAMINATION:
LICENSE NUMBER:
BOARD RATING:

MILITARY SCHOOLING:

TRAINING:

*COURSE NAME SCHOOL CONDUCTED BY DATE FROM-TO

SCHOOLING:

*COURSE NAME SCHOOL CONDUCTED BY DATE FROM-TO

SEMINAR:

*COURSE NAME SCHOOL CONDUCTED BY DATE FROM-TO

WORK HISTORY:

OCCUPATION:

*POSITION:
COMPANY NAME:
DATE FROM: DATE TO; ____________________

AWARDS AND DECORATIONS:

MILITARY AWARD:

*AWARD TYPE *AWARD *ACHIEVEMENT *AUTHORITY

DESCRIPTION

APPRECIATION/ RECOGNITION, PLAQUE OF MERIT, SPECIAL AWARDS:

*AWARD TYPE *AWARD *ACHIEVEMENT *AUTHORITY

DESCRIPTION

COMMENDATION:

*GIVEN BY *DATE AWARD

SIGNATURE OVER PRINTED NAME