CONFIDENTIAL

PERSONAL HISTORY STATEMENT

INSTRUCTIONS:

1. Answer all questions completely. If questions are not applicable, write “NA”. Write “UNKNOWN”
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 you do not have sufficient space.

2. Type, print or write carefully. Illegible or incomplete will not receive consideration.

WARNING

1. The corrections to all statements or entries made herein will be investigated.

2. Type print or write carefully: Illegible or material facts may give sufficient cause for denial of
clearance.

3. That statements made herein are classified CONFIDENTIAL. Revelation or use of other than
authorized purpose is prohibited.

I. PERSONAL DETAILS:

LAST NAME :____________________ FIRST NAME ___________________ MIDDLE INITIAL___________

NICKNAME _________________ MAIDEN NAME ___________________ CIVIL STATUS _______________

RANK _________ SERIAL NUMBER __________________ BRANCH OF SERVICE ____________________

DATE OF BIRTH _______________ PLACE OF BIRTH ________________RELIGION _______________

HOME ADDRESS: (House Nr, St, Brgy/Bo) _____________________________________________________

MUN/TOWN, CITY OR PROV: _______________________________________________________________

HOME TEL NR: _______________ OCCUPATION___________________NATIONALITY ________________

UNIT/OFFICE ___________________ UNIT OFFICE ADDRESS ____________________________________

POSITION/DESIGNATION _______________ UNIT/OFFICE TEL NR ________ CITIZENSHIP____________

DATE OF MARRIAGE: ___________ PLACE OF MARRIAGE _____________________ TIN _____________

CHANGE NAME: _______________________________ ETHICAL/TRIBAL GROUP: ___________________

CIVILIAN ID: __________________________________ GSIS POLICY NR: ___________________________

EMAIL ADDRESS: _____________________________________ CELLPHONE NR: ____________________

II. PERSONAL CHARACTERISTICS

SEX __________ AGE __________ BLOOD TYPE __________ BUILD __________ EYES _____________

HAIR: _______________ WEIGHT (kgs) ________ HEIGHT _________ COMPLEXION _________________

PHYSICAL CONDITION: ______________________ RECENT SERIOUS ILLNESS: ____________________

DISTINGUISHING FEATURE: _______________________________________________________________

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III. MARITAL HISTORY

SPOUSE NAME _______________________ MIDDLE NAME ____________ NICKNAME _______________

DATE OF BIRTH ____________________ PLACE OF BIRTH ______________________________________

HOME ADDRESS _____________________________________________ HOME TEL NR_______________

OCCUPATION _______________________________ OFFICE ADDRESS: ___________________________

OFFICE TEL NR _____________ NATIONALITY ______________ DATE NATURALIZED _______________

PLACE NATURALIZED ____________________________________________________________________

CHILDREN (USE BACK SPACE FOR MORE DATA):

NAME DATE OF BIRTH ADDRESS AGE

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_______________________________________________________________________________________

IV. FAMILY HISTORY AND INFORMATION

FATHER _______________________ NATIONALITY __________________ CITIZENSHIP ______________

DATE OF BIRTH ____________ PLACE OF BIRTH _______________ OCCUPATION __________________

HOME ADDRESS _______________________________________ TEL NR __________________________

PLACE OF EMPLOYMENT _________________________________________________________________

MOTHER _______________________ NATIONALITY __________________ CITIZENSHIP ______________

DATE OF BIRTH ____________ PLACE OF BIRTH _______________ OCCUPATION __________________

HOME ADDRESS _______________________________________ TEL NR __________________________

PLACE OF EMPLOYMENT _________________________________________________________________

GUARDIAN_____________________ NATIONALITY __________________ CITIZENSHIP ______________

DATE OF BIRTH ____________ PLACE OF BIRTH _______________ OCCUPATION __________________

HOME ADDRESS _______________________________________ TEL NR __________________________

PLACE OF EMPLOYMENT _________________________________________________________________

FATHER IN LAW _______________________ NATIONALITY ______________ CITIZENSHIP ___________

DATE OF BIRTH ____________ PLACE OF BIRTH _______________ OCCUPATION __________________

HOME ADDRESS _______________________________________ TEL NR __________________________

PLACE OF EMPLOYMENT _________________________________________________________________

MOTHER IN LAW _______________________ NATIONALITY ______________ CITIZENSHIP ___________

DATE OF BIRTH ____________ PLACE OF BIRTH _______________ OCCUPATION __________________

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HOME ADDRESS _______________________________________ TEL NR __________________________

PLACE OF EMPLOYMENT _________________________________________________________________

DEPENDENTS (USE BACK SPACE FOR MORE DATA)

NAME RELATIONSHIP DATE OF BIRTH

_______________________________ _________________________ _______________________
_______________________________ _________________________ _______________________
_______________________________ _________________________ _______________________
_______________________________ _________________________ _______________________
BROTHERS AND SISTERS (USE BACK SPACE FOR MORE DATA)

NAME AGE MARITAL STATUS ADDRESS OCCUPATION

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

V. EDUCATIONAL BACKGROUND

A. ELEMENTARY

NAME OF SCHOOL LOCATION INCLUSIVE DATES DEGREE/AWARDS EARNED

________________________________________________________________________________________
________________________________________________________________________________________

B. HIGH SCHOOL

NAME OF SCHOOL LOCATION INCLUSIVE DATES DEGREE/AWARDS EARNED

________________________________________________________________________________________
________________________________________________________________________________________

C. COLLEGE

NAME OF SCHOOL LOCATION INCLUSIVE DATES DEGREE/AWARDS EARNED

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

D. POST GRADUATE

NAME OF SCHOOL LOCATION INCLUSIVE DATES DEGREE/AWARDS EARNED

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

E. OTHER SCHOOLS/TRAINING ATTENDED

TRAINING COURSES INCLUSIVE DATES CONDUCTED BY

_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________ _______________________
_________________________ _______________________
_________________________ _______________________
_________________________ _______________________
_________________________ _______________________
_________________________ _______________________
_________________________ _______________________
_________________________ _______________________
_________________________ _______________________
_________________________ _______________________

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F. ELIGIBILITY

CIVIL SERVICE ELIGIBILITY DATE OF EXAM RATING PLACE OF EXAM

______________________________ ______________ ___________ _________________
______________________________ ______________ ___________ _________________

VI. MILITARY HISTORY

DATE ENTERED SVC:_______________________________ AUTHORITY OF ENTRY TO SVC: __________

DATE OF ENLISTMENT: _________________________ AUTHORITY OF ENLISTMENT: _______________

DATE OF COMMISSION: ________________________ SOURCE OF COMMISSION ___________________

DATE OF COMPULSORY RETIREMENT ________ LATEST NR OF LP ______ SR LINEAL LIST NR _____

PROBATIONARY/CADETSHIP/TRAINEE/DRAFTEE (USE BACK SPACE FOR MORE DATA)

RANK EFF DATE INCLUSIVE DATE AUTHORITY REMARKS

________________________________________________________________________________________
________________________________________________________________________________________

ETAD/ EO 79/ AADT/ FILLER (USE BACK SPACE FOR MORE DATA)

RANK EFF DATE INCLUSIVE DATE AUTHORITY REMARKS

________________________________________________________________________________________
________________________________________________________________________________________

REENLISTMENT RECORDS (USE BACK SPACE FOR MORE DATA)

RANK REENLISTED EFFECTIVITY AUTHORITY

________________________________________________________________________________________
________________________________________________________________________________________

SERVICE RECORDS For Civilian Personnel Only (USE BACK SPACE FOR MORE DATA)

INCLUSIVE DATES POSITION DEPARTMENT/AGENCY SALARY REASON FOR LEAVING

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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PRESENT DUTY ASSIGNMENT

DESIGNATION UNIT DATE REMARKS

______________________ _______________ ______________ PRIMARY
______________________ _______________ ______________ SECONDARY
______________________ _______________ ______________ _________________ TEMPORARY

SIGNIFICANT ASSIGNMENT

POSITION/DESIGNATION UNIT DATE FROM DATE TO

______________________________ ______________ _______________ _________________

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______________________________ ______________ _______________ _________________

PROMOTION/DEMOTION (USE BACK SPACE FOR MORE DATA)

EFF DATE RANK/GRADE AUTHORITY REMARKS

____________________ ______________ _____________________ _______________________
____________________ ______________ _____________________ _______________________
____________________ ______________ _____________________ _______________________

AWARDS/DECORATIONS (USE BACK PAGE FOR MORE DATA)

DECORATIONS/AWARDS/COMMENDATIONS DATE AWARDED AUTHORITY

______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
_____________________ _______________________
_____________________ _______________________
_____________________ _______________________
_____________________ _______________________
_____________________ _______________________

MILITARY SCHOOLING (USE BACK PAGE FOR MORE DATA)

1. CAREER COURSES:

COURSE NAME OF SCHOOL INCLUSIVE DATE GRADE STANDING

BASIC
________________________________________________________________________________________
________________________________________________________________________________________

ADVANCE
________________________________________________________________________________________
________________________________________________________________________________________

GSC/JCSC/MNSA
________________________________________________________________________________________
________________________________________________________________________________________

2. INTELLIGENCE COURSES

COURSE NAME OF SCHOOL INCLUSIVE DATE GRADE STANDING

BASIC
________________________________________________________________________________________
________________________________________________________________________________________

ADVANCE
________________________________________________________________________________________
________________________________________________________________________________________

OTHER INTELLIGENCE COURSES/TRAININGS/SEMINARS (USE BACK SPACE FOR MORE DATA)

COURSES/TRNG/SEM NAME OF SCHOOL INCLUSIVE DATES REMARKS

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

3. OTHER MILITARY COURSES/TRAINING/SEMINARS (USE BACK SPACE FOR MORE DATA)

COURSES/TRNG/SEM NAME OF SCHOOL INCLUSIVE DATES REMARKS

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

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TRAININGS/SEMINARS NAME OF SCHOOL INCLUSIVE DATES REMARKS

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

4. SPECIAL SKILLS
________________________________________________________________________________________
________________________________________________________________________________________

5. OTHER QUALIFICATIONS
________________________________________________________________________________________
________________________________________________________________________________________

6. LANGUAGES/DIALECTS

LANGUAGES/DIALECTS SPEAK READ WRITE

_______________________________ _______________ _______________ _________________
_______________________________ _______________ _______________ _________________
_______________________________ _______________ _______________ _________________

VII. ORGANIZATION (USE BACK SPACE FOR MORE DATA)

ORGANIZATION NAME ORGANIZATION ADDRESS DATE OF MEMBERSHIP POSITION HELD

_____________________ ________________________ ____________________ _________________
_____________________ ________________________ ____________________ _________________
_____________________ ________________________ ____________________ _________________
_____________________ ________________________ ____________________ _________________

VII. PLACE OF RESIDENCE SINCE BIRTH (USE BACK SPACE FOR MORE DATA)

PLACE OF RESIDENCE SINCE BIRTH INCLUSIVE DATES

______________________________________________________________ _______________________
______________________________________________________________ _______________________
______________________________________________________________ _______________________
______________________________________________________________ _______________________

IX. COUNTRIES VISITED (USE BACK SPACE FOR MORE DATA)

COUNTRIES PURPOSE OF VISIT DATE VISITED

_________________________ _______________________________ _______________________
_________________________ _______________________________ _______________________
_________________________ _______________________________ _______________________

ARREST RECORD AND CONDUCT:

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.
____________________________________________________________________________________________

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HAS ANY MEMBER OF YOUR FAMILY 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. _______________________________________________________________________

HAVE YOU EVER BEEN CHARGED OF ANY ADMINISTRATIVE CASE? YES ( ) NO ( ) IF SO, EXPLAIN:
____________________________________________________________________________________________

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 OF THE CASE AND THE
PLACE OF YOUR DETENTION. _________________________________________________________________

DO YOU USE INTOXICATING LIQUOR OR NARCOTICS? YES ( ) NO ( ) IF SO, TO WHAT EXTENT?

____________________________________________________________________________________________

X. GENERAL REPUTATION

CHARACTER REFERENCES

LENGTH OF
NAME BUSINESS ADDRESS OCCUPATION ACQUAINTANCE
_______________________ ____________________ _______________ _________________
_______________________ ____________________ _______________ _________________
_______________________ ____________________ _______________ _________________
_______________________ ____________________ _______________ _________________

NEIGHBOR RESIDENCE
NAME
_________________________________
_________________________________
_________________________________
_________________________________
BUSINESS ADDRESS
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________

XI. CREDIT REPUTATION:

ARE YOU ENTIRELY DEPENDENT ON YOUR SALARY? YES ( ) NO ( ) IF NO, STATE OTHER SOURCES OF
INCOME: ____________________________________________________________________________________

NAME AND ADDRESS OF BANKS OR OTHER CREDIT INSTITUTIONS WITH WHICH YOU HAVE
ACCOUNTS/LOANS: __________________________________________________________________________

HAVE YOU FILED A STATEMENT OF YOUR ASSETS AND LIABILITIES WITH ANY GOVERNMENT AGENCY?
YES ( ) NO ( ) IF SO, WHAT AGENCY? ____________________________________________________________

HAVE YOU FILED YOUR LATEST INCOME TAX RETURNS? __________________________________________

AMOUNT PAID FOR THE LAST CALENDAR YEAR:____________________________________
______________

CREDIT REFERENCES
NAME
__________________________________________
__________________________________________
__________________________________________
__________________________________________
BUSINESS ADDRESS
_________________________________________
_________________________________________
_________________________________________
_________________________________________

XIII. HANDWRITTEN SPECIMEN: Copy exactly the following paragraph in your own handwriting

“As Luis E Rapazo III of 105th 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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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 as to a material fact will constitute ground for immediate denial of my application
for clearance.

Signed at _____________________________________ Date: ______________________________

_____________________________ _____________________________
(Witness) (Signature of Applicant)

____________________________
(Witness)

THUMB MARKS:

(Left) (Right)

SUBSCRIBED AND SWORN to before me this___ day of _____________20___, Philippines, Affiant exhibited
to me his/her Community Tax Certificate Nr. _________ issued at _______________ on ________________

________________________________
________________________________
________________________________
(Administering Officer)

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Note: Draw a sketch of your present residence on this page.

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