PERSONAL HISTORY STATEMENT

GHQ B2

File Nr:___________

200-52

INSTRUCTION:

1. Answer all questions completely, if the question is not applicable, write NA, UNKNOWN only if
you do not know the answer and cannot obtain the answer from personal record. Use the blank
pages at the back of this form for extra details on any question or which you do not have
sufficient space.
2. Type, print, or write carefully, illegible or incomplete for will not receive consideration.

WARNING

1. The correctness of all statement of entries made herein well be investigated.

2. Any deliberate omission of distortion of material facts may give sufficient cause or denial of
clearance.
3. The statements made herein are classified CONFIDENTIAL. Revelation or use for either than the
authorized purpose is prohibited by AFPRG-200-052.

1. PERSONAL DETAILS:
A. Name:_____________________________ Rank: _______ SN: _______ Br or svc: _________
Last First Middle
B. Present job/assignment: _______________________________________________________
C. Business or Duty Address: ______________________________________________________
D. Home Address: ______________________________________________________________
E. Provincial Address:____________________________________________________________
F. Date of Birth:________________________________________________________________
G. Change in Name (if by court, give details) _________________________________________
H. Nickname: ______________________ Nationality: __________________________________
I. TIN: _____________________ GSIS: _____________Nat’l Reg. Card: ___________________

II. PERSONAL CHARACTERISTICS:

A. Description: Age:___________ Height: _________ Weight: _____________________

Build (Heavy, Medium, Light): ______________ Complexion (Dark, Fair, Light): __________
Color of eyes: ___________________ Color of Hair: _________________________________
Scar, Marks and other distinguishing features: _____________________________________
B. Physical condition: present status of health (Excellent, Good, Poor): ____________________
Physical or mental defects: _____________________________________________________
Recent serious illness: _________________________________________________________

III. MARITAL STATUS:

A. ___________________________________________________________________________
(Single / Married / Separated / Widow)
B. Name of Spouse: _____________________________________________________________
(Full Name)
Date and place Married: _______________________________________________________
Occupation and place of employment: ___________________________________________
C. Children:

Name: Date of Birth: Citizenship and Address

 ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

IV. FAMILY HISTORY AND INFORMATION:

A. Father: _____________________________________________________________________
Date of birth: ________________________________________________________________
Address: ____________________________________________________________________
Occupation and Place of Employment: ___________________________________________
Citizenship: ________ If naturalized, give date and place where naturalized ______________
B. Mother: ____________________________________________________________________
Date of birth: ________________________________________________________________
Address: ____________________________________________________________________
Occupation and Place of Employment: ___________________________________________
Citizenship: ________ If naturalized, give date and place where naturalized ______________

C. Brother and sisters:

Name Age Address Occupation

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

D. Steps Parents and Guardian ____________________________________________________

Address: ____________________________________________________________________
Occupation and Place of Employment ____________________________________________
Citizenship __________(If naturalized, give date and place where naturalized) ___________
E. Father In Law: _______________________________________________________________
Address: ____________________________________________________________________
Occupation and Place of Employment ____________________________________________
Citizenship __________(If naturalized, give date and place where naturalized) ___________
F. Mother In Law: ______________________________________________________________
Address: ____________________________________________________________________
Occupation and Place of Employment ____________________________________________
Citizenship __________(If naturalized, give date and place where naturalized) ___________

V. PLACE OF RESIDENCE SINCE BIRTH:

Inclusive Dates Complete Address

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

VI. EDUCATIONAL BACKGROUND:

A. Elementary: Location Dates of Attendance Year Graduated

_____________________________________________________________________________
 B. High School:
_____________________________________________________________________________
C: College:
_____________________________________________________________________________
D: Post Graduated:
________________________________________________________________________________
E: Other School Attend and dates of Attendance:
________________________________________________________________________________
F: Civil service Eligibility, if any other similar qualification acquired:
________________________________________________________________________________

VII. MILITARY HISTORY:

A. Date Enlisted in the AFP: __________________________________________________________

B. Date Of Commission: _____________________________________________________________
C. Important assignment since enlisted/CAD: ____________________________________________
D. Military school attended:
Name of school/location/date of Attendance/Nature of Course or Training:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
E. Decoration, Awards, or Commendations received:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Letter of Commendation received from:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

VII. EMPLOYMENT:

Inclusive date: Type of employment: Name and Address of Employment: Nature of Leaving
______________________________________________________________________________

Have you ever been dismissed or force to resign from a position? Yes _____________________
______________________________________________________________________________

X. CREDIT REPUTATION:

A. Are you entirely dependent on your salary? Yes ____ No ____ if no state other source of income
______________________________________________________________________________
B. Name and address of bank or other credit institution with which you have accounts:
______________________________________________________________________________
______________________________________________________________________________
C. Have you file a statement of assets and liabilities with any government agencies? ____________
 Yes _______ No ________ If so, what Agency _________________________________________
D. Have you File your latest income tax return: __________________________________________
E. Three (3) credit references in the Philippines:

Name Address
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

XI. ARREST RECORD AND CONDUCT:

A. Have you ever been investigated, indicator or convicted for any violation of the law? if so State
the name of the court, nature of offense and disposition of case: _________________________
______________________________________________________________________________
B. Has any member of your family ever been investigated, indicated or convicted for any violation
of the law? If so state the name of the court, nature of offense and disposition of case:
______________________________________________________________________________
C. Have you ever been Charge in any Administrative case, If so, explained:
______________________________________________________________________________
D. Have you ever been arrested or detained pursuant to the provision of PD 1081 and its
implementation order (GO, SO, LOI) If so, State the nature of the case and place of your
detention ______________________________________________________________________
E. Do you use intoxicated liquor or narcotics? If so, to what extent? _________________________

XII. GENERAL REPUTATION:

A. Give Five (5 Character references)

Name Business Address or Residence

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

B. List Down Three (3) neighbours at your present address:

Name Business Address/Residence

(Include Street and Number)

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
XII. ORGANIZATION:

List of organization or social groups, which you have been a member of:

Organization Address Date of Membership Position Held

______________________________________________________________________________

XIV. MISCELLANEOUS:

A. Hobbies, Sports, and past Time

______________________________________________________________________________

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

Language or dialects Speak Read Write

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

C. Are you willing to undergo a periodic lie detector test? ______________________________

D. Copy exactly the following paragraph in your own handwriting.

As luis repazo III of q05th Xavier ave. guzzled his way through three bottles of brandy
Josephine Z Quinzing a partner of the law firm of sam diego and Ballasteros, located at2879
valley forge st. Quezon City turned to Richard ting Sr., a Chinese food expert fom Q.k.
Kwantong Company Ltd,346 Hadji Jairula Hussien 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”
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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 ______________________________

_____________________________
( Signature )
 ____________________________ ____________________________
( Witness ) ( Witness )

THUMBMARKS:

LEFT RIGHT

SUBSCRIBED AND SWORN to before me this _______________ day of __________________________ at

____________________ Philippines, affiant exhibited to me his/her residence certificate
Nr ____________________ issued on ___________________ At ________________________________

________________________________

(Administering Officer)

Note: 1. Include Location sketch of present residence.

2. Attach two latest (2x2) pictures without headgear.