CONFIDENTIAL

ANNEX A of AFPR G 200-054 dtd 22 September 2014;

GHQ, OJ2 File Nr: ______________

200-054 Form

PERSONAL HISTORY STATEMENT

INTRUCTIONS

1. Answer all questions completely; if question is not applicable, write “N/A”. 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: ____________________

C. PRESENT JOB/ASSIGNMENT: __________________________________________________

D. BUSINESS OR DUTY ADDRESS: ________________________________________________

(Signature of Applicant)

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

__________________________________________________________________________________

F. BIRTHDATE:_________________ PLACE: ________________________________________

G. CHANGE IN NAME (If 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: ____________________

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II. PERSONAL CHARACTERISTICS:

A. DESCRIPTION: Sex: ________ Age: ________ Height: ________ (M) Weight: ________ (Kg)

Built (Heavy, Medium, Light): ____________________________________________________

Complexion (Dark, Fair, Light) ____________________ Color of Eyes: ___________________

Color of Hair: _____________ Scars or marks and 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 Widow)

B. NAME OF SPOUSE: __________________________________________________________

(Full Name)

Date and Place of Marriage: ___________________________________________________________

Date of Birth: ____________________ Spouse Place of Birth: ________________________________

Occupation/Employer/Place of Employment: ______________________________________________

__________________________________________________________________________________

Contact Number: __________________ Citizenship: _________________ If dual, ________________

(Other Citizenship)
C. CHILDREN:

Name Date of Birth Citizenship/Address Name of Father/

Mother
(Signature of Applicant)

(Use back page for additional information)

IV. FAMILY HISTORY AND INFORMATION:

A. Father: _____________________________________________________________________
(Full Name)

Date/Place of Birth: ____________________________________________________________

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

Complete Address: ____________________________________________________________

Occupation/Employer/Place of Employment: ________________________________________

____________________________________________________________________________

Citizenship: _______________________ If dual, write both citizenship. 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 citizenship. 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: ____________________________________________________________

Occupation/Employer/Place of Employment: ________________________________________

Citizenship: _______________________ If dual, write both citizenship. If naturalized, give date

and place where naturalized _____________________________________________________

E. FATHER-IN-LAW: _____________________________________________________________
(Signature of Applicant)

(Full Name)

Date & Place of Birth: __________________________________________________________

Complete Address: ____________________________________________________________

Occupation/Employer/Place of Employment: ________________________________________

Citizenship: _______________________ If dual, write both citizenship. If naturalized, give date

and place where naturalized _____________________________________________________

F. MOTHER-IN-LAW: ____________________________________________________________
(Full Name)

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

Date & Place of Birth: __________________________________________________________

Complete Address: ____________________________________________________________

Occupation/Employer/Place of Employment: ________________________________________

Citizenship: _______________________ If dual, write both citizenship. 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

C. College Location Date of Year

Attendance Graduated

D. Post Graduate Location Date of Year

Attendance Graduated
(Signature of Applicant)

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

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

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VI. MILITARY HISTORY:

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 OF OFFICE

E. Military Schools Attended:

School/Location Date of Nature of Rating

Attendance Training
(Signature of Applicant)

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

F. Decorations, Awards or Commendations Received:

(Use additional sheets if necessary)

VII. PLACES OF RESIDENCE SINCE BIRTH:

VIII. EMPLOYMENT:

Inclusive Date Type of Employment Name and Address of Employer Reason for
Leaving
(Signature of Applicant)

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

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IX. FOREIGN COUNTRIES VISITED:

Date of Visit Country 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. Names and addresses of banks or other credit institutions which you have account/loans:
_______________________________________________________________________________________
_______________________________________________________________________________________

C. Have you filed a statement of your Assets and Liabilities with any government agency?
Yes ( ) No ( ) If so, what agency?_______________________________________________

D. Have you file your latest Income Tax Returns? ______________________________________

E. Three (3) Credit Reference in the Philippines:

Name Address
(Signature of Applicant)

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

D. Have you ever been arrested or detained pursuant to the provisions of PD 1081 and its
implementing orders (GO, PD, LOI)? Yes ( ) No ( ) If so, state nature of the case and the place of your
detention. _______________________________________________________________________________
_______________________________________________________________________________________

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

XII. GENERAL REPUTATION:

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

Name Address

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

Name Address
(Signature of Applicant)

XIII. ORGANIZATIONS:

C. List of organizations and social groups which you have been a member of

Organization Address Date of Membership Position Held

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XIV. MISCELLANEOUS:

D. Hobbies, sports and past time:

E. Language and dialects (indicate ability as Fluent, Fair or Poor)

Language/Dialect Speak Read Write

F. Are you willing to undergo periodic lie detector test? __________________________________

G. Copy exactly the following paragraph in your own handwriting:

As Luis Repaso III of 105th Xavier Ave. guzzled his way through three bottles of brandy, Josephine
Z Quinzing, a partner in the law firm of San Diego and Ballesteros located at 2679 Valley Forge St. Quezon City
turned to Richard Ting Sr, a Chinese Food Expert from O. W. Ewaman Company Ltd. 346 Hadji Jairula Blvd.
and said, “I cant speak for my government but I’m quite sure your country and mine goes together for closer
understanding”
(Signature of Applicant)

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

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

Signed at ____________________________________ Date _______________________

_______________________________ _______________________________
(Witness) (Signature of Applicant)

_______________________________
(Witness)

THUMB MARKS:

(Left) (Right)

SUBSCRIBED AND SWORN to before me this ___________ of ________________________

Philippines. Affiant exhibiting to me his/her Community Tax Certificate Nr. ____________________________
issued at ________________________ on ____________________________________________.

_________________________________________

_________________________________________

_________________________________________
(Administering Officer)

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

SKETCH OF THE LOCATION OF RESIDENCE

(Signature of Applicant)

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