1X1

SECURITY DEPARTMENT PHOTO

PERSONAL HISTORY STATEMENT
POSITION / COMPANY NAME:
SURNAME
FIRST NAME
MIDDLE NAME NAME EXTENSION (eg.
DATE OF BIRTH DAY MONTH YEAR Jr., Sr.)
COMPLETE MAILING POSTAL ADDRESS

PLACE OF BIRTH
RELIGION
SEX MALE FEMALE
CIVIL SINGLE ANNULLED SEPERATED ZIP CODE
STATU MARRIED WINDO TELEPHONE NO
S OTHERS,SPECIFY_________
CITIZENSHIP COMPLETE PR0V.
HEIGHT
WEIGHT (KG)
BLOOD TYPE ZIP CODE
TIN TELEPHONE NO
PAG-IBIG NO E-MAIL ADDRESS
PHILHEALTH NO CELLPHONE NO
SSS NO
FAMILY BACKGROUND
SPOUSE LAST NAME OF CHILD (WRITE FULL NAME AND DATE OF BIRTH
LIST ALL) (mm dd
NAME yyyy)
FIRST NAME 1. / /
MIDDLE NAME 2. / /
OCCUPATION 3. / /
EMPLOYER/ 4. / /
BUSINESS 5.
TELEPHONE NO. / /
FATHER LAST 6. / /
NAME
7. / /
FIRST NAME
MIDDLE NAME 8. / /
MOTHER LAST 9.
NAME
/ /
FIRST NAME 10. / /
MIDDLE NAME (CONTINUE ON SEPARATE SHEET IF NECESSARY)

(at the back)

EDUCATIONAL BACKGROUND
SCHOLARSHIP/
NAME OF SCHOOL DEGREE / COURSE
LEVEL YEAR ACADEMIC
(Write in full)
 GRADUATED HONORS
RECEIVED
ELEMENTARY
SECONDARY
VOCATIONAL/TRADE
COURSE
COLLEGE
GRADUATE STUDIES
EMPLOYMENT BACKGROUND
INCLUSIVE POSITION TITLE DEPARTMENT / MONTHLY STATUS OF REASON FOR LIVING
DATES (WRITE IN AGENCY / SALARY APPOINTMENT
(mm/dd/yy) FULL) OFFICE /
From To COMPANY

PERSON TO BE CONTACTED IN CASE OF EMERGENCY

Name and Address: ________________________________________________________________________
Tel / Cell Nos.: ____________________________________________________________________________

LANGUAGE SPOKEN (INDICATE ABILITY FAIR OR FLUENT)

1. ___________________________________ 4. __________________________________
2. ___________________________________ 5. __________________________________
3. ___________________________________ 6. _________________________________

REFERENCES (Person not related to you)

NAME NATURE OF WORK ADDRESS TEL NO.

I hereby certify that the information I provided herein are accurate and complete.

________________________________________________
PRINT NAME AND SIGNATURE

Date: ____________________
VICINITY SKETCH OF RESIDENCE

Draw a map that shows how to get from your residence to Brgy Hall or Municipal Hall. Indicate landmarks and
names of major streets and use an “X” to mark your house on the map.