PCGA APPLICATION FORM

PHILIPPINE COAST GUARD AUXILIARY

_____ AUXILIARY SQUADRON
MEMBERSHIP APPLICATION
( ) New Enrollment ( ) Re-enrollment ( ) Transfer of Squadron
SECTION I – PERSONAL DATA OF APPLICANT
LAST NAME FIRST NAME MIDDLE NAME SUFFIX GENDER
BORJA DOREENA JOY CAPISTRANO ( ) Male
( / ) Female
OTHER NAMES USED:
Dhee-Jheiy

HOME ADDRESS
Purok 7, Bagong-Bayan, Dili, Gasan, Marinduque

MARITAL STATUS NAME OF SPOUSE NO. OF CHILDREN

( ) Single ( / ) Married ( ) Separated JUVEL R. BORJA 2

( ) Widow/Widower
HEIGHT WEIGHT COLOR OF EYES COLOR OF HAIR
5’1 89 Black Black

SCARS OR MARKS AND OTHER DISTINGUISHING FEATURES:

SSS/GSIS NO. DATE OF BIRTH PLACE OF BIRTH

2005328204 July 21, 1992 Dili, Gasan, Marinduque
CITIZENSHIP RELIGION BLOOD TYPE
Filipino Roman Catholic AB+
TEL. NO. (HOME) TEL. NO. (BUSINESS) MOBILE NUMBER
(042) 754 - 2097 09171474583
EMAIL 1 EMAIL 2 FAX NO.
[email protected] [email protected]
ACR NO. (IF ALIEN) PASSPORT NO./EXPIRE DATE TYPE OF VISA ISSUED TIN NO.
343-608-429

SECTION II – EDUCATIONAL BACKGROUND – College/Post-Grad/Special Studies

NAME OF SCHOOL DEGREES OBTAINED INCLUSIVE DATES YEAR GRADUATED

Marinduque State College BS Information Technology 2008-2012 2012

Certificate for Professional
Marinduque State College Teachers Education 2014
Master in Information
University of the East Technology 2017 -2019 2019
(Attach photocopies of either the transcript of records, diploma or PRC certificate)
SECTION III – EMPLOYMENT/OCCUPATIONAL BACKGROUND
( √ ) EMPLOYED ( ) OWN BUSINESS
COMPANY NATURE OF BUSINESS DESIGNATION INCLUSIVE DATES

Marinduque State College Higher Education - Academe Assistant Professor I 2017 - present

(Attach latest employment’s certification, SEC registration, Art. Of Incorporation or DTI Registration)
FOR PAST OR CURRENTLY IN GOVERNMENT POSITION – Please state highest Appointed/Elected Office
Position/Period Assumed: Assistant Professor I
Nature of Office: Higher Education - Academe
(Attach certification from the Office concerned)
SECTION IV – ADDITIONAL DATA
PROFESSIONAL LICENSES:
SPECIAL TRAININGS: National Certificate II – Computer Servicing System
SPECIAL INTERESTS/SKILLS: Database Management, Software Engineering

(Attach photocopies of license/s or certificate/s)

MA – 2009 Page 2 of 4 MEMBERSHIP APPLICATION

SECTION V – EMERGENCY CONTACT INFORMATION
LAST NAME FIRST NAME MI SUFFIX RELATIONSHIP

Capistrano Marilou L Mother

ADDRESS

Bagong Bayan, Dili, Gasan, Marinduque

TEL NO. (HOME) TEL NO. (BUSINESS) MOBILE NUMBER

09283893589
SECTION VI – READINESS INPUT
A. FUNCTIONS YOU WANTED TO BE INVOLVED IN: (Please check choice/s)
( ) MARSAR – Maritime Search and Rescue
( / ) MAREP – Marine Environmental Protection
( ) MARSAF – Maritime Safety
( / ) COMREL – Community Relations (Civic action activities i.e. Medical/Dental Missions; Youth development)
B. ANSWER B1 AND CHECK APPROPRIATE ANSWERS FOR B2 to B4:
1. What is your purpose in joining the PCGA? (in at least 50 words you may use separate sheet)
2. Are you willing to be trained? ( √ ) Yes ( ) No
3. Are you willing to travel outside of your home area? ( √) Yes ( ) No
4. Are you available on call 24 hours? ( √ ) Yes ( ) No If No, need _____ days/advance notice
SECTION VII – ASSETS/RESOURCES AVAILABLE TO PCGA PROJECTS
(This data will be used for reference as available resources in times of disaster/emergency only and does not
mean a full turn-over to PCG/PCGA of said items/equipment)
ITEMS/CLASSIFICATION QUANTITY DESCRIPTION
WATERCRAFT (Boat) Name__________________ ___Type______________________
Speed_____________________ Power_____________________
None Range_____________________ Full Capacity(Ltrs/Gals)_______

AIRCRAFT

None

LAND TRANSPORTATION Name: __________ Type: MOTORCYCLE

Speed: ___ Power_____________________
None Range_____________________ Full Capacity(Ltrs/Gals)_____

AMBULANCE/FIRETRUCKS

None

OTHER EQUIPMENTS (Please specify) i.e. Communications: Telephone, 2-way radios, generators, etc.

MANPOWER (Please specify – Doctors/Dentists/Nurses/Support Staff, etc)

SECTION VIII – ORGANIZATIONS

LIST OF ORGANIZATIONS OR SOCIAL GROUPS WHICH YOU HAVE BEEN A MEMBER OF:
ORGANIZATION PLACE DATE OF MEMBERSHIP POSITION HELD
Philippine Society of MIMAROPA January 2019 - Present Member
Information Technology
Educators (PSITE)

SECTION IX – REQUIRED CLEARANCES and ATTACHMENTS

a. NBI CLEARANCE e. ENDORSEMENT LETTER FROM THE SQUADRON
b. POLICE CLEARANCE DIRECTOR
c. BARANGAY CLEARANCE
d. ORIENTATION SEMINAR CERTIFICATE (copy)

(All of the listed items must be included with the application package)
MA – 2009 Page 3 of 4 MEMBERSHIP APPLICATION
SECTION X – MISCELLANEOUS
COPY THE FOLLOWING PARAGRAPH IN YOUR OWN HANDWRITING.

“As Luis F. Repazo 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 for my
Government but I’m quite sure your country and mine better get together for closer understanding.”

SECTION XI – APPLICANT STATEMENT AND SIGNATURE

I have ( ) have not ( √ ) been convicted of a violation of any laws of the Republic of the Philippines, classified as a major
misdemeanor or a felony. (If convicted of a major misdemeanor or felony, state specifics, including date, city & state
offense/s occurred, disposition and comments and attach to this application.) I affirm under the penalties of perjury as to
the truth of all the statements contained in this Guard Auxiliary. I understand that any false statement contained herein is
ground for my disenrollment from the Philippine Coast Guard auxiliary.
I PLEDGE TO SUPPORT THE PHILIPPINE COAST GUARD AUXILIARY AND ITS PURPOSES AND TO ABIDE BY THE
GOVERNING POLICIES ESTABLISHED BY THE COMMANDANT OF THE PHILIPPINE COAST GUARD.
NAME AND SIGNATURE OF SPONSOR DATE NAME AND SIGNATURE OF APPLICANT

THUMBMARKS

LEFT RIGHT

Please paste here

2x2 colored photo
With white background

SECTION XII – SQUADRON DIRECTOR ENDORSEMENT

APPLICANT IS: SQUADRON DIRECTOR SIGNATURE DATE
( ) ACCEPTED
( ) NOT ACCEPTED

Note: If applicant is not accepted, explain in detail below

MA – 2009 4 of 4 INSTRUCTIONS
MEMBERSHIP APPLICATION
1. GENERAL – Everyone requesting membership in the Philippine Coast Guard Auxiliary must complete
this form.
a. Read all instructions carefully.
b. This form is used to supply new member personal information for entry into the Auxiliary database.
c. USE BLUE OR BLACK INK FOR COMPLETING THE WRITTEN PORTION OF ALL OF THESE
FORMS.
2. SECTION I – PERSONAL DATA OF THE APPLICANT – To be completed by applicant.
a. LAST NAME, FIRST NAME, MIDDLE NAME and SUFFIX – Enter full legal name.
b. OTHER NAMES USED – List all other names you were known by or are now using. If you are
female, and or have been married, include maiden name, and other married names if married more
than once. Identify maiden name with “NEE”.
c. GENDER – Check one of the genders.
d. HOME ADDRESS – Enter current home address.
e. MARITAL STATUS – Check one of the marital status.
f. NAME OF SPOUSE – Use spouse’s given name – no nicknames.
g. NO. OF CHILDREN – Indicate number.
h. HEIGHT, WEIGHT, COLOR OF EYES, COLOR OF HAIR – Enter appropriate answers.
i. SCARS OR MARKS AND OTHER DISTINGUISHING FEATURES – Enter description.
j. SSS/GSIS NO. – Enter SSS or GSIS No. as the case maybe.
k. DATE OF BIRTH, PLACE OF BIRTH – Enter DOB using MM/DD/YY numeric format, 01/18/45.
Membership eligibility begins at 18 years of age.
l. CITIZENSHIP, RELIGION, BLOOD TYPE – Enter appropriate answers.
m. TEL NOS. (HOME), (BUSINESS) & MOBILE PHONE – ENTER PHONE NUMBERS.
n. EMAIL 1, EMAIL 2 & FAX NO. – Enter email addresses and fax no.
o. ACR NO./PASSPORT NO./EXPIRY DATE, TYPE OF VISA & TIN NO. – Enter corresponding nos.
Attach photo copies of ACR AND PASSPORT.
3. SECTION II – EDUCATIONAL BACKGROUND – College/Post-Grad/Special Studies – To be
completed by applicant
a. Enter appropriate answers
b. Attach photocopies of either the transcript of records, diploma or PRC certificate.
4. SECTION III – EMPLOYMENT/OCCUPATIONAL BACKGROUND – To be completed by applicant
a. Enter appropriate answers.
b. Attach latest employment’s certification, SEC Registration, Articles of Incorporation or DTI
Registration. If government employee, attach certification from the office concerned.
5. SECTION IV – ADDITIONAL DATA – To be completed by applicant.
a. Enter appropriate answers.
b. Attach photo copies of license/s or certificate/s.
6. SECTION V – EMERGENCY CONTACT INFORMATION – To be completed by applicant.
a. Enter name, emergency contact’s relationship, address and phone numbers.
7. SECTION VI – READINESS INPUT – to be completed by the applicant after the orientation seminar.
a. Check B1 in at least 50 words. You may use a separate sheet.
b. Check appropriate answers for B2 to B4.
8. SECTION VII – ASSETS/RESOURCES AVAILABLE TO PCGA PROJECTS – To be completed by
applicant after the orientation seminar.
a. Enter appropriate answers.
9. SECTION VIII – ORGANIZATIONS – To be completed by applicant
a. Enter appropriate answers.
10. SECTION IX – REQUIRED CLEARANCES AND ATTACHMENTS – To be attached to application
a. NBI Clearance (Original and 3 copies)
b. Police Clearance (Original and 3 copies)
c. Barangay Clearance (Original and 3 copies)
d. Orientation Seminar Certificate (copy)
e. Endorsement letter from the Squadron Director.
11. SECTION X – MISCELLANEOUS – To be completed by applicant.
a. To be copied by the applicant in his own handwriting.
12. SECTION XI – APPLICANT STATE AND SIGNATURE – To be completed by the applicant and
sponsor.
a. Felony/misdemeanor convictions – check appropriate answers to convicted statement. Review
application and data ensure accuracy, then sign and indicate date using either blue or black ink.
The sponsor will co-sign the statement. The applicant will affix his thumb marks and attach his 2x2
picture.
13. SECTION XII – SQUADRON DIRECTOR ENDORSEMENT – To be completed by the Squadron
Director.
a. The Squadron Director check appropriate decision then sign the application form and indicate date.