<p> C O N F I D E N T I A L</p><p>(When Filled) 200.52 FILE ______GHQ B2 PERSONAL HISTORY STATEMENT</p><p>INSTRUCTION</p><p>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.</p><p>2. Types, print, or write carefully; illegible or incomplete forms will not receive consideration.</p><p>3. When in doubt ask for assistance.</p><p>W A R N I N G</p><p>1. The correctness of all statement of entries made herein will be investigated.</p><p>2. The statements made herein are classified CONFIDENTIAL. Revelation or use for other than the authorized purpose is prohibited by AFPR G 200-053.</p><p>I. PERSONAL DETAILS</p><p>A. Name: ______Last First Middle/Maternal</p><p>B. RanK: ______AFSN: ______BR OF SVC: ______</p><p>B C. Present Job/Assignment: ______Tel. No. ______</p><p>D. Business or Duty Address: ______Tel No. ______</p><p>E. Home Address, (Include Street & No.) ______Tel No. ______</p><p>F. Birth: Date ______Place ______</p><p>G. Change in Name (If by Court Action, give details) ______</p><p>H. Nickname: ______Nationality:______</p><p>I. TIN: ______National Reg. Card No. ______</p><p>II. PERSONAL CHARACTERISTICS</p><p>A. Description: Sex ______Age ______Height ______(Meter) </p><p>Weight ______kg; Build (Heavy, Medium, Slight) ______</p><p>Complexion (Dark, Fair, Light) ______Color of Eyes______</p><p>Color of Hair ______Blood Type ______</p><p>1 C O N F I D E N T I A L</p><p>Scars or marks and other distinguishing features: ______</p><p>B. Physical Condition:</p><p>Present State of health (Excellent, Good, Poor) ______</p><p>Physical or Mental Defects ______</p><p>Recent serious Illness ______</p><p>III. MARITAL HISTORY:</p><p>A. Marital Status: ______(Single, Married, Separated or Widowed)</p><p>B. Name of Spouse: ______(Full Name)</p><p>Date and Place of Marriage: ______Birth: Date______Place ______Occupation and Place of employment:______</p><p>B. Children:</p><p>Name Date of Birth Citizenship & Address ______</p><p>(Use separate sheet for additional information)</p><p>IV. FAMILY HISTORY AND INFORMATION</p><p>A. Father______(Full Name) Date and Place of Birth:______</p><p>Occupation and Place of Employment:______</p><p>Citizenship:______If naturalized, give date and place where naturalized______</p><p>B. Mother______(Full Name) Date and Place of Birth:______Occupation and Place of Employment:______Citizenship:______If naturalized, give date and place where naturalized______</p><p>C. Step Parent or Guardian:______</p><p>Address:______</p><p>2 C O N F I D E N T I A L</p><p>Occupation and Place of Employment:______Citizenship:______If naturalized, give date and place where naturalized:______</p><p>D. FatherIn-Law: ______</p><p>Address:______Occupation and Place of Employment:______Citizenship:______If naturalized, give date and place where naturalized:______</p><p>E. Mother-In-Law: ______</p><p>Address:______Occupation and Place of Employment: ______Citizenship:______If naturalized, give date and place where naturalized:______</p><p>V. EDUCATIONAL BACKGROUND:</p><p>A. Elementary Location Date of Attendance Year Graduated ______</p><p>B. High School ______</p><p>C. College ______</p><p>D. Post Graduate ______</p><p>E. Other School Attended and Date of Attendance ______</p><p>F. Civil Service Eligibility, if any and other similar qualifications acquired: ______</p><p>VI. MILITARY HISTORY:</p><p>A. Date Enlisted in the AFP: ______B. Date of Commission: ______Source of Commission: ______C. Important Unit Assignment Since Enlistment/CAD. ______</p><p>3 C O N F I D E N T I A L</p><p>______</p><p>C. Military Schoolings Attended:</p><p>Name of School/Location Date of Nature of Rating Attendance Training ______</p><p>D. Decoration, Awards or Commendations Received: ______</p><p>VII. PLACE OF RESIDENCE SINCE BIRTH:</p><p>Inclusive Dates Address ______</p><p>VIII. EMPLOYMENT:</p><p>Inclusive Type of Name/Address Reason Dates Employment of Employer For Leaving ______</p><p>Have you ever been dismissed or forced to resign from a position: ( ) Yes ( ) No if Yes, explain______</p><p>IX. FOREIGN COUNTRIES VISITED:</p><p>Date Country Visited Purpose of Visit ______</p><p>4 C O N F I D E N T I A L</p><p>______</p><p>X. CREDIT REPUTATION:</p><p>A. Are you entirely dependent on your salary: Yes ( ) No ( ) If no, state other sources of income______</p><p>B. Names and address of Banks or other credit Institutions with Which you have accounts/loans: ______</p><p>C. Have you filled a statement of you asset and Liabilities with any government agency Yes ( ) No ( ) If so What Agency: ______</p><p>D. Have you filled your latest Income Tax Return:______Amount paid for the last Calendar Year______</p><p>E. Three (3) Credit References in the Philippines</p><p>Name Address ______</p><p>XI. ARREST RECORD AND CONDUCT:</p><p>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.______</p><p>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.______</p><p>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.______</p><p>D. Have you ever charged in any administrative Case:______If so, explain______</p><p>E. Do you use intoxicating liquor or narcotics:______If so, to what extent:______</p><p>5 C O N F I D E N T I A L</p><p>XII. GENERAL REPUTATION:</p><p>A. Give five (5) character references (Known for three years or longer who your relatives are)</p><p>Name Business Address ______</p><p>B. List down three (3) neighbors at your present residence.</p><p>Name Business Address ______</p><p>XIII. ORGANIZATION:</p><p>List of organizations or social groups which you have been a member of:</p><p>Organization Address Date of Membership & Position Held ______</p><p>XIV. MISCELLANEOUS: </p><p>A. HOBBIES, Sports and Past Times:______B. Language and Dialect (Indicate ability as fluent, fair poor) Language of Dialect Speak Read Write ______</p><p>C. Are you willing to undergo periodic lie detector test: ______</p><p>D. Copy exactly the following paragraph in own handwriting.</p><p>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”. ______</p><p>6 C O N F I D E N T I A L</p><p>______</p><p>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.</p><p>Signed at ______Date______</p><p>______(Witness) (Signature of Applicant)</p><p>______(Witness)</p><p>Picture 2 x 2</p><p>THUMB MARKS</p><p>LEFT RIGHT</p><p>Subscribed and sworn to before me this ______day ______of 20____ at ______Philippines.</p><p>______Administering Officer/Notary public</p><p>______(Rank & Designation)</p><p>______TIN</p><p>7 C O N F I D E N T I A L</p><p>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 </p><p>Date______20______</p><p>Submitted by______Address______(Indicate office or agency if data herein is not submitted by individual concern)</p><p>Name______Age______</p><p>Address______</p><p>Place of Birth______Date of Birth______</p><p>Citizenship______Marital Status______</p><p>Educational Attainment______Occupation ______</p><p>Language and Dialects______</p><p>Civil Organizations______</p><p>Scars & Marks______</p><p>Race______Height______Weight______</p><p>Eyes______Blood Type ______Hair______Build______</p><p>Complexion______Pecularities______</p><p>In Case of Naturalized Filipinas:</p><p>Petition Nr______Name and Address of nearest relative or person to be notified in case of emergency. ______</p><p>2x2 Picture</p><p>Purpose:______Data furnished By______Data Verified By______Important: Pls include all requested data.</p><p>8 C O N F I D E N T I A L</p><p>PERSONAL IDENTIFICATION Fingerprints Chart</p><p>PAF Nr ______Handwriting Specimen Nr ______</p><p>Name______(Surname) (Given Name) (Middle Name) (Photo Nr)</p><p>Nickname:______Classification ______</p><p>Color______Sex______Reference______</p><p>Classified By ______Verified By ______</p><p>RIGHT HAND 1.THUMB : 2. INDEX FINGER :3. MIDDLE FINGER : 4.RING FINGER : 5. LITTLE FONGER : : : : : : : : : : : : : : : : : : : :______</p><p>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</p><p>9</p>