CONFIDENTIAL

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

GHQ, OJ2 File Nr_________________

200-54 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 and cannot obtain the answer from
personal records. Use blank spaces at the back of this form for extra details on any
questions 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 or entries made herein will be investigated.

2. Any deliberate omission or distortion of materials, facts may give sufficient

cause for denial of clearance.

3. The statements made herein are classified CONFIDENTIAL. Revelation or

use for other than authorized purpose is prohibited under the provisions of AFPR G 200-054.

I. PERSONAL DATA:

A. NAME: Pamatian John Robert Rosano

(Last) (First) (Middle/Maternal)

B. RANK: ASSK AFPSN: 960849 BR OF SVC: PN

C. PRESENT JOB/ASSIGNMENT: Duty EP LOC NLC

D. BUSINESS OR DUTY ADDRESS: HNLC,LOC, Fort San Felipe, Cavite City

E. HOME ADDRESS (include street & number) Mangas 1 Alfonso Cavite

F. BIRTHDATE: 17 May 1995 PLACE: Parañaque City

G. CHANGE IN NAME(If by court action, give details) N/A

H. NICKNAMES: Janjan NATIONALITY: Filipino

I. TAX IDENTIFICATION NR: 351-684-132 TEL NO. N/A

I. MOBILE PHONE NR: 09750743537 E-MAIL ADDRESS:

pamatianjohnrobert@Gmail.com

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: Male Age: 27 Height: 5’4 (M) Weight: 65

(kgs)

Build (Heavy, Medium, Light): Medium

Complexion (Dark, Fair, Light): Fair Color of Eyes: Brown

Color of Hair: black Scars or Marks & Other Distinguishing Features: mole
on the nose

B. PHYSICAL CONDITION

Present State of Health (Excellent, Good, Poor): Good

Recent Serious Illness: N/A

Blood Type: A+

III. MARITAL HISTORY:

A. MARITAL STATUS: Married

(Single, Married, Separated or Widowed)

B. NAME OF SPOUSE: Nikkie P Pamatian

(Full Name)

Date & Place of Marriage: 08 Aug 2022 /Alfonso, Cavite

Date of Birth: 23 Dec 1994 Place of Birth: Silang Cavite

Occupation/Employer/Place of Employment: DepEd

Contact Number: 09509044990 Citizenship: Filipino If dual, N/A

(Other Citizenship)

C. CHILDREN:

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

N/A N/A N/A N/A

N/A N/A N/A N/A
N/A N/A N/A N/A
N/A N/A N/A N/A
N/A N/A N/A N/A

(Use back page for additional information)

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

IV. FAMILY HISTORY AND INFORMATION:

A. FATHER: Fernando C Pamatian

(Full Name)

Date & Place of Birth: 05 January 1961 Ibajay Aklan

Complete Address: Ibajay Aklan

Occupation/Employer/Place of Employment: Deceased

Citizenship: Filipino If dual, write both citizenship, if naturalized,

give date and place where naturalized) N/A

B. MOTHER: Marites R Pamatian

(Full Name)
Date & Place of Birth: 22 Jul 1968 Mangas 1 Alfonso Cavite

Complete Address: Mangas 1 Alfonso Cavite

Occupation/Employer/Place of Employment: House wife

Citizenship: Filipino If dual, write both citizenship. If naturalized,

give date and place where naturalized

C. BROTHERS & SISTERS:

NAME DATE OF CITIZENSHIP COMPLETE ADDRESS OCCUPATION EMPLOYER/

BIRTH (IF DUAL, ADDRESS
WRITE BOTH)
Bryan R Pamatian Mangas 1,
Mangas 1, Alfonso Trycicle
15 Mar 91 Filipino Alfonso
Cavite driver
Cavite
Catherine R Pamatian 01 Feb 97 Filipino Mangas 1, Alfonso Reservist Tanza
Cavite Army Cavite
N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A

D. STEP- PARENT OR GUARDIAN: N/A

(Full Name)
Date & Place of Birth: N/A

Complete Address: N/A

Occupation/Employer/Place of Employment: N/A

Citizenship: N/A If dual, write both citizenship. If naturalized,
give date and place where naturalized N/A

E. FATHER-IN-LAW: Martiniano P Peji

(Full Name)
Date & Place of Birth: 11 Nov 1965/Alfonso Cavite

Complete Address: Esperanza Ilaya Alfonso Cavite

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Occupation/Employer/Place of Employment: Farmer

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

Citizenship: N/A If dual, write both citizenship. If naturalized,

give date and place where naturalized: N/A

F. MOTHER-IN-LAW: Carmencita R Peji

(Full Name)
Date & Place of Birth: 22 Mar 1965/ Alfonso Cavite Cavite

Complete Address: Esperanza Ilaya Alfonso Cavite

Occupation & Place of Employment: N/A
Citizenship: Filipino If dual, write both citizenship. If naturalized,
give date and place where naturalized: N/A

V. EDUCATIONAL BACKGROUND:

A. Elementary Location Date of Year

Attendance Graduated

Mangas Elementary School Mangas 1 Alfonso, Cavite 1994 1998

______

______

B. High School Location Date of Year

Attendance Graduated

Alfonso National High Scool Alfonso, Cavite 2006 2011

______

C. College Location Date of Course Taken

Attendance Year Graduated

Sacred Heart Mangas 1Alfonso, Cavite 2011 HRM

2013

D. Post Graduate Location Date of Course Taken/

Attendance Graduated Year

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N/A N/A N/A N/A

N/A N/A N/A N/A
N/A N/A N/A N/A

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

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

N/A
N/A
N/A

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

Acquired:
N/A
N/A
N/A

VI. MILITARY HISTORY:

A. Date Enlisted in the AFP: 29 November 2019

B. Date of Commission: 21 May 2020

C. Source of Commission: Phil. Navy (AFP)

D. Important Unit Assignments since Enlistment/CAD:

HNLC, , Fort San Felipe, Cavite City

E. Military Schools Attended::

School/Location Date of Attendance Nature of Training Rating

SBC CL-04/ 29 Nov 2019-21May2009 SBC 85.691

NETDC, San Antonio,
Zambales

F. Decorations, Awards or Commendations Received::

___________
_________ ________
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___________ ________
_________ ___
______ ______
______________________________________

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

PLACES OF RESIDENCE SINCE BIRTH:

Inclusive Dates Address

Since Birth to Present Mangas 1, Alfonso Cavite

VII. EMPLOYMENT:

Inclusive Type of Name/Address Reason for

Date Employment of Employer Leaving

N/A N/A N/A N/A

N/A N/A N/A N/A
N/A N/A N/A N/A
N/A N/A N/A N/A

Have you ever been dismissed or forced to resign from a position: No (√ ) Yes ( ).
If yes, explain
N/A
N/A
N/A

VIII. FOREIGN COUNTRIES VISITED:

Date of Visit Country Visited Purpose of Visit Address Abroad

N/A

IX. CREDIT REPUTATION:

 A. Are you entirely dependent on you 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:
PNSLAI AND AFPSLAI- SANGLEY POINT Cavite City

C. Have you filed a statement of your Assets and Liabilities with any government
Agency? Yes ( √ ) No ( ) If so, what Agency and when? OESPA PHILIPPINE NAVY

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

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Amount paid for the last Calendar Year:

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

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

Name Address
PO3 Lorna R Ocampo Bancod Indang Cavite
SN1 Ramon D Rosano Mangas 1 AlfonsoCavite
ASN Aljon P Perez Indang Cavite

X. ARREST RECORD 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. N/A

B. Have any member of your immediate family 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. N/A

C. Have you ever been charged of any administrative case? Yes ( ) No (√ ) If

so. Explain: N/A

D. Have you ever been arrested or detained pursuant to the provisions of PD

1081and it’s implementing orders (GO, PD, LOI)? Yes ( ) No ( √ ). If so. State the
nature of the case and the place of your detention. N/A

E. Do you use intoxicating liquor or illegal drugs? Yes ( ) No ( √ ) if so, to what

extent?
N/A

XI. GENERAL REPUTATION:

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

Name Address
Mr Ariel M Rosano Mangas 1, Alfonso Cavite
Mark Dave M Credo Mangas 1, Alfonso Cavite
Amado C Baclao Mangas 1, Alfonso Cavite
Marites B Sipagan Mangas 1, Alfonso Cavite
Danilo C Baclao Mangas 1, Alfonso Cavite

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

Name Address
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Rhovean C Baclao Mangas 1, Alfonso Cavite

Nely C Baclao Mangas 1, Alfonso Cavite
Rosemarie V Pamatian Mangas 1, Alfonso Cavite

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

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

Organization Address Date of Position

Membership Held
AFPSLAI Sangley PT Cavite City 2020 Member

XIII. MISCELLANEOUS:

D. Hobbies, sports and past times.

Volleyball, jogging, cooking

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

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

Language/Dialect Speak Read Write

English Fair Fair Fair

Tagalog Fluent Fluent Fluent
___________________________________________________________________

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

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

As Luis E. Rapazo 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 2879 Valley Forge St., Quezon City turned to Richard Ting Sr., a
Chinese food expert from O.W. Kwantung Company Ltd.,346 Hadji Jairula Hussein Blvd.,
and said “ I can’t speak for my government but I’m quite sure your country and mine better
get together for closer understanding.”

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

I certify that the foregoing answers are true and correct to the best of my
knowledge and belief and I agree that any misstatement or omission to the material fact will
constitute ground for immediate denial of my application for clearance.

Signed at HNLC NSPL FSF Cavite City Date: 06 February 2023

(Signature of Applicant)

(Witness)

(Witness) 2x2 Photo

THUMB MARKS

(LEFT) (RIGHT)

SUBSCRIBED AND SWORN before me this 06 day of February 2023

Philippines. Affiant exhibited to me his/her Military ID No. PN-EP-06056 issued at
Fort Bonifacio Tagiug City on 03 September 2020.

______
(Administering Officer)

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

Sketch of Residence

HNLC, NSPL, FSF,

Cavite City

Mangas 1,Alfonso
Cavite
Pamatian Residence

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