C O N F I D E N T I AL

(When Filled)
200.52
GHQ B2

FILE __________
PERSONAL HISTORY STATEMENT
INSTRUCTION

1.
Answer all question completely. If question is not applicable write NA.
Use the blank pages at the back of this form extra details on any question or questions
for which you do not have sufficient space.
2.
Types, print, or write carefully; illegible or incomplete forms will not receive
consideration.
3.

When in doubt ask for assistance.

WAR N I N G

1.
The correctness of all statement of entries made herein will be
investigated.
2.
The statements made herein are classified CONFIDENTIAL. Revelation
or use for other than the authorized purpose is prohibited by AFPR G 200-053.
I.

PERSONAL DETAILS
A.

Name: _____________________________________________________
Last
First
Middle/Maternal

B.

RanK: __________AFSN: ____________BR OF SVC: _______________

C.

Present Job/Assignment: ______________________________________

______________________________________Tel. No. ______________

D.

Business or Duty Address: _____________________________________

______________________________________Tel No. ______________

E.

Home Address, (Include Street & No.) ____________________________

______________________________________Tel No. ______________

F.

Birth: Date ___________________Place _________________________

G.

Change in Name (If by Court Action, give details) __________________

__________________________________________________________

H.

Nickname: ________________________ Nationality:________________

I.

TIN: _____________________ National Reg. Card No. ______________

II.

PERSONAL CHARACTERISTICS
A.

Description: Sex ________Age ________Height _______(Meter)

Weight __________kg; Build (Heavy, Medium, Slight) ___________
Complexion (Dark, Fair, Light) ___________Color of Eyes________
Color of Hair _________________ Blood Type ________________

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Scars or marks and other distinguishing features: ______________

B.

Physical Condition:
Present State of health (Excellent, Good, Poor) ________________
Physical or Mental Defects _________________________________
Recent serious Illness ____________________________________

III.

MARITAL HISTORY:
A.

Marital Status: __________________________________________

(Single, Married, Separated or Widowed)

B.

Name of Spouse: _______________________________________

(Full Name)
Date and Place of Marriage: _______________________________
Birth: Date____________________Place ____________________
Occupation and Place of employment:________________________
______________________________________________________

B.

Children:
Name
___________
_____________
_____________

Date of Birth
____________
____________
____________

Citizenship & Address

__________________
__________________
__________________

(Use separate sheet for additional information)

IV.FAMILY HISTORY AND INFORMATION
A. Father______________________________________________
(Full Name)
Date and Place of Birth:________________________________
Occupation and Place of Employment:____________________
___________________________________________________
Citizenship:_____________ If naturalized, give date and place where
naturalized________________________________________________
B. Mother_____________________________________________________
(Full Name)
Date and Place of Birth:______________________________________
Occupation and Place of Employment:__________________________
_________________________________________________________
Citizenship:_____________ If naturalized, give date and place where
naturalized________________________________________________
C. Step Parent or Guardian:_____________________________________
Address:____________________________________________________

C O N F I D E N T I AL

Occupation and Place of Employment:____________________________

Citizenship:______________________If naturalized, give date and place
where naturalized:__________________________________________
D. FatherIn-Law: _____________________________________________
Address:____________________________________________________
Occupation and Place of Employment:____________________________
___________________________________________________________
Citizenship:____________________If naturalized, give date and place
where naturalized:___________________________________________
E. Mother-In-Law: _____________________________________________
Address:_____________________________________________________
Occupation and Place of Employment: _____________________________
____________________________________________________________
Citizenship:___________________If naturalized, give date and place
where naturalized:____________________________________________
V. EDUCATIONAL BACKGROUND:
A. Elementary
__________
__________
__________

Location
________
________
________

Date of Attendance
________________
________________
________________

Year Graduated
______________
______________
______________

B. High School
__________
__________

________
________

________________
________________

______________
______________

C. College
__________
__________

________
________

________________
________________

______________
______________

D. Post Graduate
__________ ________
__________ ________

________________
________________

______________
______________

E. Other School Attended and Date of Attendance

__________________________________________________________
F. Civil Service Eligibility, if any and other similar qualifications acquired:
__________________________________________________________
VI. MILITARY HISTORY:
A.
Date Enlisted in the AFP: ___________________________________
B.
Date of Commission: __________Source of Commission: _________
C.
Important Unit Assignment Since Enlistment/CAD.
_____________________________________________________________
_____________________________________________________________

C O N F I D E N T I AL

_____________________________________________________________
C.

Military Schoolings Attended:

Name of School/Location
____________________
____________________
____________________
____________________
____________________
____________________
____________________

D.

VII.

Nature of
Training
________
________
________
________
________
________
________

Rating
_______
_______
_______
_______
_______
_______
_______

Decoration, Awards or Commendations Received:

______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
PLACE OF RESIDENCE SINCE BIRTH:
Inclusive Dates
________________
________________
________________
________________
________________
________________
________________

VIII.

Date of
Attendance
_________
_________
_________
_________
_________
_________
_________

Address
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________

EMPLOYMENT:
Inclusive
Type of
Name/Address
Reason
Dates
Employment of Employer
For Leaving
_____________ _____________ ______________ _____________
_____________ _____________ ______________ _____________
_____________ _____________ ______________ _____________
Have you ever been dismissed or forced to resign from a position:
( ) Yes ( ) No if Yes, explain________________________________
_________________________________________________________

IX.

FOREIGN COUNTRIES VISITED:

Date
__________

Country Visited
Purpose of Visit
_____________________ ______________________

C O N F I D E N T I AL

__________
X.

_____________________ ______________________

CREDIT REPUTATION:
A.

Are you entirely dependent on your salary: Yes ( ) No ( )

If no, state other sources of income_____________________________
_________________________________________________________

B.

Names and address of Banks or other credit Institutions with

Which you have accounts/loans:
_________________________________________________________
_________________________________________________________

C.

Have you filled a statement of you asset and Liabilities with any
government agency Yes ( ) No ( ) If so What Agency: ______
__________________________________________________________

D.

Have you filled your latest Income Tax Return:_____________________

Amount paid for the last Calendar Year___________________________

E.

Three (3) Credit References in the Philippines

Name
_________________________
_________________________
_________________________

XI.

Address
______________________________
______________________________
______________________________

ARREST RECORD AND CONDUCT:

A. Have you ever been investigated/arrested, indicated or convicted for any

violation of law: If so, state name of court, nature of offense and disposition
of case.________________________________________________________
B. Has any member of your family ever been investigated/arrested indicated or
convicted for nay violation of Law: If so state name of court, nature of offense
and disposition case.______________________________________________
_______________________________________________________________
C. Have you ever been arrested or detained pursuant to the provisions of
1081 and its implementing orders (GO, PD, LOI): If so, state the nature of the
case
and
the
place
of
your
detention.________________________________________________________
________________________________________________________________
D. Have you ever charged in any administrative Case:______________________
If so, explain_____________________________________________________
E. Do you use intoxicating liquor or narcotics:_____________________________
If so, to what extent:_______________________________________________

C O N F I D E N T I AL

XII. GENERAL REPUTATION:

A. Give five (5) character references (Known for three years or longer
your relatives are)
Name
_________________________
_________________________
_________________________
_________________________
_________________________

who

Business Address
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

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

Name
_________________________
_________________________
_________________________
XIII.

Business Address
_____________________________________
_____________________________________
_____________________________________

ORGANIZATION:

List of organizations or social groups which you have been a member of:
Organization
____________
____________
XIV.
A.
B.

Address
Date of Membership & Position Held
______________ ___________________________________
______________ ___________________________________

MISCELLANEOUS:
HOBBIES, Sports and Past Times:_______________________________
__________________________________________________
Language and Dialect (Indicate ability as fluent, fair poor)
Language of Dialect Speak
Read
Write
________________ _____
______
______
________________ _____
______
______
________________ _____
______
______

C.

Are you willing to undergo periodic lie detector test:

__________________________________________________________

D.

Copy exactly the following paragraph in 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 Force St., Quezon City turned to Richard Ting St.,
a Chinese food expert from O.W. Kwantung Company, Ltd., 346Hadji Jairula Blvd.,
and said : I cant speak for my government but Im quite sure your country and mine
better get together for closer understanding.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

C O N F I D E N T I AL

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

Signed at _____________________________Date______________
_____________________________
(Witness)

_________________________
(Signature of Applicant)

_____________________________
(Witness)

Picture 2 x 2

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Subscribed and sworn to before me this _________ day _______of 20____ at

________________________ Philippines.
________________________________
Administering Officer/Notary public
_________________________________
(Rank & Designation)
_________________________________
TIN

C O N F I D E N T I AL

REPUBLICNOF THE PHILIPPINES

DEPARTMENT OF NATIONAL DEFENSE
PH I L I P I N E AI R F O R C E
CLEARANCE, IDENTIFICATION & RECORDS DIVISION
Date_________________20______
Submitted by_____________________________ Address__________________
(Indicate office or agency if data herein is not submitted by individual concern)
Name_____________________________________ Age___________________
Address_________________________________________________________
Place of Birth___________________________ Date of Birth_______________
Citizenship____________________________ Marital Status_______________
Educational Attainment___________________ Occupation ________________
Language and Dialects_______________________________________________
Civil Organizations_________________________________________________
Scars & Marks_____________________________________________________
Race__________________ Height__________________ Weight____________
Eyes___________ Blood Type ________ Hair_________ Build______________
Complexion___________________Pecularities___________________________
In Case of Naturalized Filipinas:
Petition Nr______________________ Name and Address of nearest relative
or person to be notified in case of
emergency.
______________________________
______________________________
2x2 Picture

Purpose:______________________
Data furnished By______________
Data Verified By_______________
Important: Pls include all requested
data.

C O N F I D E N T I AL

PERSONAL IDENTIFICATION
Fingerprints Chart
PAF Nr _______________
Handwriting Specimen Nr _______________
Name__________________________________________________________
(Surname)
(Given Name)
(Middle Name)
(Photo Nr)
Nickname:___________________ Classification _________________________
Color________________________ Sex______________ Reference__________
Classified By __________________Verified By __________________________
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Taking Prints)
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Note Amputation

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