REQUIREMENT

1. C O N F I D E N T I A L
C O N F I D E N T I A L
PERSONAL HISTORY STATEMENT
GHQ B2 File Nr___
200-52
I N S T R U C T I O N S
1. Answer all questions completely, if questions are not applicable write “NA”. Write “UNKNOWN” only if
you do not know the answer and cannot obtain the answer from the personal records. Use blank space at
the back of this form for extra details on any question or which you do not have sufficPient 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 may give sufficient cause for denial of clearance.
3. The statements made herein are classified “CONFIDENTIAL”. Revelation or use for other than the
authorized purpose is prohibited by AFP G 200-052.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
I. PERSONAL DETAILS:
A. Name: _____ ____ __________________________Rank:______ ___ AFPSN: ______
Last First Middle
B. Present Job Assignment: ________________________________________________________
C. Business or Duty Address: _______________________________________________________
D. Home Address: _________________ ______________________
E. Provincial Address: _____________________________________________________________
F. Birth Date: __________________ Birth Place: _________________ _____________________
G. Change in Name (if by Court, give detail): __No_______________________________________
H. Nick Name: ___________ Nationality:______________________________________________
I. TIN: _______________ GSIS: ____________ Nat’l Reg Card: ____________
J. Religion: ________
II. PERSONAL CHARACTERISTICS:
A. Description: Sex: ____Age:_____ Height: ____ _ Weight:_______
Build (heavy/medium/slight): _________ Complexion(dark/fair/light): ___________
Color of eyes: ____________ Color of hair: __________
Scars, Marks and other distinguishing features: ___________________________________
B. Physical Condition Present Status of Health (excellent/good/poor): ___________________
Physical or Mental Defect: _________
Record Serious Illness: _________
III. MARITAL HISTORY:
A. Marital status: __ ________________________
(single/married/separated/widowed)
B. Name of Spouse: _____________________________________________
C. Birth Date; __________________ Place: _________________________
D. Children:
Name Date of Birth Citizenship and Address

2. C O N F I D E N T I A L
C O N F I D E N T I A L
IV. FAMILY HISTORY AND INFORMATION:
A. Father: _____________ __________________ Birth Date: ______________________
Place of Birth: _______________________________________________________ ______
Residential Address: ______________________________________________________________
Occupation and Place of Employment: ________________________________________________
Citizenship: ____________(if naturalized given date & place where naturalized) _______________
____________________________________________________________________________
B. Mother: _ _______________________________ Birth Date: ___________
Place of Birth: __________________________________________________________________
Residential Address: __________________________ __________________________________
Occupation and Place of Employment: _________________________________________
Citizenship: ___________________(if naturalized given date & place where naturalized) ____
_____________________________________________________________________
C. Brothers and Sisters:
Name Age Address Occupation
D. Step Parents or Guardian: _________________________________________________________
Address: _____________________________________________________________________
Occupation and Place of Employment: _____________________________________________
Citizenship: ________________(if naturalized given date & place where naturalized) _______
E. Father-in-Law: ______________________________________________________________
Address: ______________________________________________________________________
Occupation and Place of Employment: ______________________________________________
Citizenship: ________ (if naturalized given date & place where naturalized) _______________
F. Mother-in-Law: ______________________________________________________________
Address:_____________________________________________________________________
Occupation and Place of Employment: ___________ ___________________________________
Citizenship: __________if naturalized given date & place where naturalized) ___________
V. PLACE OF RESIDENCE SINCE BIRTH:
Inclusive Dates Complete Address
VI. EDUCATIONAL BACKGROUND:
A. Elementary:
Location Date of Attendance Year Graduated
B. High School:
Location Date of Attendance Year Graduated

3. C O N F I D E N T I A L
C O N F I D E N T I A L
C. College:
Location Date of Attendance Year Graduated
D. Post Graduate:
Location Date of Attendance Year Graduated
E. Other Schools Attended and Date of Attendance:
Location Date of Attendance Year Graduated
F. Civil Service Eligibility, if any and other similar institutions:
Location Date of Attendance Year Graduated
VII. MILITARY HISTORY:
A. Date CAD/Enlisted in the AFP:______________________
B. Source of Commissioned/Enlistment: _________________
C. Important unit assignments since CAD/Enlisted in the AFP:
Unit Date Covered
D. Military Schooling Attended:
Name of School Date of Attendance Nature of Training Rating
E. Awards, Decorations and Commendation Received:
TYPE OF AWARD ACHIEVEMENTS AUTHORITY
VIII. EMPLOYMENT:
Inclusive Date Type of Employment Name & Address of Nature of Leaving
Employment
Have you ever been dismissed or forced to resign from your position? Yes ____ No____
If yes, explain: ______________________________________________________________________
IX. FOREIGN COUNTRIES VISITED:
Inclusive Date Country Visited Purpose of Visit

4. C O N F I D E N T I A L
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 so,
State other source of income: _____________________________________________________
B. Name and address of banks or other credit institutions with which you have accounts/loans:
_____________ - ___________________________________________________
_____________ - ___________________________________________________
C. Have you filed your statement of assets and liabilities with any government agency? Yes ____
No ___ If so, what agency? Philippine Navy
D. Have you filed your latest income tax return? Yes
E. Three (3) Credit Reference in the Philippines:
Name Address
XI. ARREST RECORDS AND CONDUCT:
A. Have you ever been arrested/investigated, indicted, or convicted for any violation of the law? ___
If so, state name of court, nature of offense and disposition of the case. ___________________
B. Has any member of your family investigated/arrested, indicted or convicted for any violation of law?
No If yes, state name of court, nature of offense and disposition of the case. _______________
C. Have you ever been charge any administrative case? ____ If yes, explain. _______________
D. Have you ever been arrested or detained pursuant to the provision of PD 1081 and its implementing
orders (GO, PO, LOI)? __ If so, state nature of the case and place of your detention___
E. Do you take in intoxicating liquor or narcotics? ___ If so, to what extent? ___________________
XII. GENERAL REPUTATION:
A. Give five (5) character references known three (3) years or longer who are not relative.
Name Business/Home Address
B. List down three (3) neighbors at your present residence:
Name Business/Home Address
XIII. ORGANIZATION OR SOCIAL GROUPS WHICH YOU HAVE BEEN A MEMBER OF:
Organization Address Date of Membership/Position

5. C O N F I D E N T I A L
C O N F I D E N T I A L
XIV. MISCELLANEOUS:
A. Hobbies and past time: ___________________________________________________
B. Language and Dialects (indicate as fluent/fair/poor)
Language Speak Read Write
C. Are you willing to undergo a periodic lie detector test? Yes ___ No ___
D. Copy exactly the following paragraph in your own handwriting:
“As Luis E Repazo III of 105th
Xavier Avenue guzzled his way through three bottles of brandy,
Josephine Z Quinzin, a partner in law firm San Diego and Ballesteros located at 287 Valley Force Street,
Quezon City turned to Richard Ting Sr., a Chinese food expert from O. W. Kwantung Company Ltd., 346
Hadji Jairula Hussein 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 material facts will constitute ground for immediate denial
of my application for clearance.
Signed at: ____________________________ Date: __________________________
____________________________
(Signature of Applicant)
Left Right
________________________
(Witness Signature)
________________________
(Witness Signature)
Subscribed and sworn to before me this _____ _ of _________ ___ at _________ Philippines,
affiant exhibited to me his Residence Certificate Nr ________ issued at ___________ Philippines.
LTJG JEREMY IVAN A MOJICA PN
(Administering Officer/Notary)
Chief, RSB, NPMC
(Designation)
2 x 2 Pictures

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