CONFIDENTIAL

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

GHQ, OJ2 File Nr : ____________

200-054 Form

PERSONAL HISTORY STATEMENT

INSTRUCTIONS

1. Answer all questions completely; if question is not applicable, write “NA”. 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: ________________________________________________

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

__________________________________________________________________________
(Signature of Applicant)

F. BIRTHDATE: __________________________ PLACE:______________________________

G. CHANGE IN NAME (If by 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: (kgs)

Build (Heavy, Medium, Light): __________________________________________________

Complexion (Dark, Fair, Light): _______________________Color of Eyes: ______________

Color of Hair: ______________ Scars or Marks & 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 Widowed)

B. NAME OF SPOUSE: _________________________________________________________

(Full Name)

Date & Place of Marriage: _____________________________________________________

Date of Birth: _____________________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

Course Taken/
C. College Location Date of Year
Attendance Graduated

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

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

Attendance Training Rating
(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:

Inclusive Dates Address

VIII. EMPLOYMENT:

Inclusive Type of Name & Address Reason for

Date Employment of Employer 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. Name and address of banks or other credit institutions with which you have accounts/loans:

D. Have you filed a statement of your Assets and Liabilities with any government Agency?
Yes ( ) No ( ) If so, what Agency and when?

D. Have you filed your latest Income Tax Returns?

Amount paid for the last Calendar Year:

E. Three (3) credit references 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 the 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 or 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 or social groups which you have been a member of

Organization Address Date of Position

Membership Held

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

XIV. MISCELLANEOUS:

D. Hobbies, sports and past times.

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 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 Forge St.,
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.”
(Signature of Applicant)

____________________________________________________________________________________________

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

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 a material fact will constitute ground for immediate denial of my
application for clearance.

Signed at Date:

(Witness) (Signature of Applicant)

(Witness)

THUMB MARKS:
2x2 Photo

(Left) (Right)

SUBSCRIBED AND SWORN to before me this ________ of ______________________

Philippines, Affiant exhibited 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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