CONFIDENTIAL

ANNEX A of AFPR G 200-054 dtd 22 September 2014 (As Amended);

GHQ, OJ2 File Nr : ____________

200-054 Form

REVISED 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 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 forms will not receive consideration.

WARNING

1. The correctness of all statements of entries made herein will be investigated.

2. Any deliberate omission or distortion of material facts is a sufficient ground for denial of
clearance.

3. The statements made herein are classified CONFIDENTIAL. Revelation or use other than the
authorized purpose is prohibited by AFPR G 200-054.

I. PERSONAL DETAILS

A. NAME: _____________________________________________________________________
(Last) (First) (Middle/Maternal)

B. RANK: _______________AFPSN:___________________BR/SVC:______________________
(Signature of Applicant)

C. PRESENT JOB/ASSIGNMENT: __________________________________________________

D. BUSINESS OR DUTY ADDRESS: ________________________________________________

E. HOME ADDRESS (Include street & number): ______________________________________

__________________________________________________________________________

F. BIRTHDATE: __________________________ PLACE:______________________________

G. CHANGE IN NAME (If by Court Action, give details): ________________________________

H. NICKNAMES: _____________________________ NATIONALITY:____________________

I. TAX IDENTIFICATION NR: ______________________ TEL NO. _____________________

J. MOBILE PHONE NR: _________________ E-MAIL ADDRESS: ________________________

K. PASSPORT NR: ___________________ DATE OF EXPIRATION: ______________________

L. SOCIAL MEDIA ACCOUNT/S___________________________________________________

ANNEX A of AFPR G 200-054 dtd 22 September 2014 (As Amended), cont’n;
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II. PERSONAL CHARACTERISTICS:

A. DESCRIPTION: Sex: Age: Height: (M) Weight: (kgs)

Build (Heavy, Medium, Light): __________________________________________________

Complexion (Dark, Fair, Light): _______________________Color of Eyes: ______________

Color of Hair: ______________ Scars or Marks & Other Distinguishing Features: ______

__________________________________________________________________________

B. PHYSICAL CONDITION:

Present State of Health (Excellent, good, Poor): ____________________________________

Recent Serious Illness: _______________________________________________________

Blood Type: ___________

III. MARITAL HISTORY

A. MARITAL STATUS: __________________________________________________________

(Single, Married, Separated or Widowed)

B. NAME OF SPOUSE: _________________________________________________________

(Full Name)

Date & Place of Marriage: _____________________________________________________

Date of Birth: _____________________Place of Birth:_______________________________

Occupation/Employer/Place of Employment: _____________________________________

___________________________________________________________________________
(Signature of Applicant)

Contact Number:_____________ Citizenship: ____________ If dual, _________________

(Other Citizenship)

C. CHILDREN:

Name Date of Birth Citizenship/Address Name of Father/

Mother

(Use back page for additional information)

IV. FAMILY HISTORY AND INFORMATION:

A. FATHER: __________________________________________________________________
(Full Name)

Date & Place of Birth _________________________________________________________

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

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Complete Address:__________________________________________________________

Occupation/Employer/Place of Employment: ______________________________________

__________________________________________________________________________

Citizenship: ______________________ If dual, write both citizenships. If naturalized, give

date and place where naturalized ___________________________________________

B. MOTHER: ________________________________________________________________
(Full Name)
Date & Place of Birth _________________________________________________________

Complete Address:__________________________________________________________

Occupation/Employer/Place of Employment: ______________________________________

Citizenship: ________________________ If dual, write both citizenships. If naturalized, give

date and place where naturalized _______________________________________________

C. BROTHERS AND SISTERS:

NAME DATE OF CITIZENSHIP (IF COMPLETE OCCUPATION EMPLOYER/ADDRESS

BIRTH DUAL, WRITE ADDRESS
BOTH)

D. STEP-PARENT OR GUARDIAN:
(Full Name)
Date & Place of Birth _________________________________________________________

Complete Address:__________________________________________________________
(Signature of Applicant)

Occupation/Employer/Place of Employment: ______________________________________

__________________________________________________________________________

Citizenship: ________________________ If dual, write both citizenships. If naturalized, give

date and place where naturalized _______________________________________________

E. FATHER-IN-LAW:
(Full Name)

Date & Place of Birth _________________________________________________________

Complete Address: __________________________________________________________

Occupation/Employer/Place of Employment: ______________________________________

__________________________________________________________________________

Citizenship: ________________________ If dual, write both citizenships. If naturalized, give

date and place where naturalized _______________________________________________

F. MOTHER-IN-LAW:
(Full Name)
ANNEX A of AFPR G 200-054 dtd 22 September 2014 (As Amended), cont’n;

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Date & Place of Birth _________________________________________________________

Complete Address: _________________________________________________________

Occupation/Employer/Place of Employment: ______________________________________

__________________________________________________________________________

Citizenship: ________________________ If dual, write both citizenships. If naturalized, give

date and place where naturalized _______________________________________________

V. EDUCATIONAL BACKGROUND

A. Elementary Location Date of Year

Attendance Graduated

B. High School Location Date of Year

Attendance Graduated

Course Taken____________
C. College Location Date of Year
Attendance Graduated
(Signature of Applicant)

Course Taken____________
D. Post Graduate Location Date of Year
Attendance Graduated

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

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

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

VI. MILITARY HISTORY:

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A. Date Enlisted in the AFP:

B. Date of Commission:

C. Source of Commission:

D. Important Unit Assignments since Enlistment/CAD:

INCLUSIVE DATES UNIT/OFFICE CHIEF/HEAD OF OFFICE

E. Military Schools Attended:

(Signature of Applicant)

School/Location Date of Nature of

Attendance Training Rating

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

F. Decorations, Awards or Commendations Received:

(Use additional sheets if necessary)

VII. PLACES OF RESIDENCE SINCE BIRTH:

Inclusive Dates Address

(Signature of Applicant)

VIII. EMPLOYMENT:

Inclusive Type of Name & Address Reason for

Date Employment of Employer Leaving

Have you ever been dismissed or forced to resign from a position: No ( ) Yes ( ) If YES, explain

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

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IX. FOREIGN COUNTRIES VISITED AND AFFILIATION/S:

Date of Visit Country/ies Visited Purpose of Visit Address Abroad

X. CREDIT REPUTATION:

A. Are you entirely dependent on your 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/loans:

C. Have you filed a statement of your Assets and Liabilities with any government Agency?
Yes ( ) If yes, what Agency and when? No ( ) If no,
state reason

D. Have you filed your latest Income Tax Returns? Yes ( ) No ( ) If no, state reason for non-
filing
(Signature of Applicant)

Amount paid for the last Calendar Year:

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

Name Address

XI. 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.

B. Has any member of your immediate 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.

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

C. Have you ever been summoned or charged of any administrative case? Yes ( ) No ( ) If so,
explain:

D. Have you ever been arrested or detained? Yes ( ) No ( ) If so, state the nature of the case
and the place of your detention.

E. Do you use intoxicating liquor? Yes ( ) No ( ) If so, to what extent?

F. Do you use illegal drugs? Yes ( ) No ( ) If so, to what extent?

XII. GENERAL REPUTATION:

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

Name Relationship Exact Address

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

Name Exact Address

(Signature of Applicant)

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

Organization Address Date of Position

Membership Held

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

D. Do you have relative(s) by affinity or consanguinity who is/are members of organizations

classified as threats to national security (i.e, Communist Party of the Philippine – New People’s Army-
National Democratic Front organizations, Abu Sayyaf Group, BIFF, Dawlah Islamiya/ Islamic State and other
Secessionist Groups? Yes ( ) No ( ) If YES, identify them:__________________________________________

E Do you have a friend or an acquaintance who is/are members of organizations classified as

threats to national security (i.e, Communist Party of the Philippines – New People’s Army- National
Democratic Front organizations, Abu Sayyaf Group, BIFF, Dawlah Islamiya/ Islamic State and other
Secessionist Groups? Yes ( ) No ( ) If YES, identify
them:____________________________________________________________

F. Do you have a family, friend or an acquaintance who have been a participant of military
adventurism, destabilization plots or coup d’etat? Yes ( ) No ( ) If YES, identify them:____________________

G. Do you have relations to individuals involved with organizations that pose a threat to national
security? Yes ( ) No ( ) If YES, identify them:____________________

H. Do you have foreign acquaintances who are government workers? Yes ( ) No ( ) If YES,
identify them:____________________

XIV. MISCELLANEOUS:

I. Hobbies, sports and past times.

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

Language/Dialect Speak Read Write

(Signature of Applicant)

K. Are you willing to undergo periodic lie detector test and/or forensic examination?

L. 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 (As Amended), cont’n;

I certify that the above-provided answers are true and correct to the best of my knowledge and belief
and I agree that any misstatement or omission as to material facts will constitute grounds for denial of my
application for Security or Command clearance and shall further serve as a basis for administrative sanctions
as deemed appropriate by competent authority.

Signed at Date:

(Witness) (Signature of Applicant)

(Witness)

THUMB MARKS:
2x2 Photo

(Left) (Right)

SUBSCRIBED AND SWORN to before me this ________ of ______________________

Philippines, Affiant exhibited to me his/her Community Tax Certificate Nr. (or valid government ID
NOT MILITARY ID) ___________________issued at ______________________on
___________________________.

________________________________

________________________________

________________________________
(Administering Officer)

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

SKETCH OF THE LOCATION OF RESIDENCE (may provide a Google Maps link provided that it is
properly labeled and can be viewed via “street view” only)
(Signature of Applicant)

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