C O N F I D E N T I A L

(When Filled) 200.52 FILE ______GHQ B2 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.

W A R 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: ______

B 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 ______

1 C O N F I D E N T I A L

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:______

2 C O N F I D E N T I A L

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. ______

3 C O N F I D E N T I A L

______

C. Military Schoolings Attended:

Name of School/Location Date of Nature of Rating Attendance Training ______

D. Decoration, Awards or Commendations Received: ______

VII. PLACE OF RESIDENCE SINCE BIRTH:

Inclusive Dates Address ______

VIII. 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 ______

4 C O N F I D E N T I A L

______

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 Address ______

XI. 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:______

5 C O N F I D E N T I A L

XII. GENERAL REPUTATION:

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

Name Business Address ______

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

Name Business Address ______

XIII. ORGANIZATION:

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

Organization Address Date of Membership & Position Held ______

XIV. MISCELLANEOUS:

A. HOBBIES, Sports and Past Times:______B. 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 can’t speak for my government but I’m quite sure your country and mine better get together for closer understanding”. ______

6 C O N F I D E N T I A L

______

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

THUMB MARKS

LEFT RIGHT

Subscribed and sworn to before me this ______day ______of 20____ at ______Philippines.

______Administering Officer/Notary public

______(Rank & Designation)

______TIN

7 C O N F I D E N T I A L

REPUBLICNOF THE PHILIPPINES DEPARTMENT OF NATIONAL DEFENSE P H I L I P I N E A I 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.

8 C O N F I D E N T I A L

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 ______

RIGHT HAND 1.THUMB : 2. INDEX FINGER :3. MIDDLE FINGER : 4.RING FINGER : 5. LITTLE FONGER : : : : : : : : : : : : : : : : : : : :______

LEFT HAND 1. THUMB : 2 .INDEX FINGER : 3. MIDDLE FINGER : 4. RING FINGER : 5. LITTLE FONGER : : : : : : : : : : : : : : : : : : : :______: : Impression taken by : Note Amputation : Signature : : ______: : (Signature of Individual : : Taking Prints) : : FOUR FINGERS TAKEN LEFT THUMB RIGHT THUMB FOUR FINGERS SIMULTANEOUSLY SIMULTANEOUSLY

9