CONFIDENTIAL

PERSONAL HISTORY STATEMENT

INSTRUCTIONS

1. Answer all the questions completely; if the 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 blanks 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 may give sufficient

cause for denial of clearance.

3. The statement made herein is classified “CONFIDENTIAL.” Revelation

or use for purposes other than that authorized is prohibited by pertinent provisions
of AFPRG 200-052.
__________________________________________________________________________

I. PERSONAL DETAILS

A. Name: Cacanindin Mark Aldrin Nidoy .

(Last) (First) (Middle)
B. Rank: _SN1 AFPSN: _007453 _ Br/Svc: __PCG ___________________ _

C. Present Job / Assignment: _HCGDNM/CGS Misamis Oriental____ ____ _

D. Business or Duty Address: _ 1280 Corrales Ext, Port Area, Cagayan De Oro City

E. Home Address (Include St. & Nr): _Purok 2 Brgy. Mucdol, Dipaculao, Aurora ,

Birth Date: _14 October 1990__ Place of Birth: Purok 2 Brgy. Mucdol, Dipaculao,
Aurora___ .
F. Change in Name (If by Court Action give details): ____N/A_______________ __

G. Nicknames: __Aldrin_____ Nationality: __Filipino ________

H. TIN: _429-644-628__ National Reg. Card: PCG CG15-E-1000_____ __ __

I. Religion: _Roman Catholic__ Blood Type: _”O” ____ ___ __

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II. PERSONAL CHARACTERISTICS

A. Description: Sex: Male_ Age: _28_ Height: __166__ (cms) Weight _65 (kgs)
Build (heavy, Medium, Light): _Medium_ Complexion (Dark, Fair, Light): _ Fair __
Color of Eyes: _Black ____________ Color of Hair: __Black_______ _____
Scars or marks and other distinguishing features: _N/A ______
B. Physical Condition/Present State of health (Excellent, Good, Poor) _Good ___
Physical or Mental Defects: __N/A__ Recent Serious Illness: __N/A__ __ ____

III. MARITAL HISTORY

A. Marital Status: ___ Single ________ _____ ____
(Single, Married, Separated or Widow)
B. Name of Spouse: _ N/A ______________________
(Full Name)
Date and Place of Marriage: N/A _
Occupation and Place of Employment: N/A _______________________
C. Children:
Name Date of Birth Citizenship
N/A N/A N/A

IV. FAMILY HISTORY AND INFORMATION

A. Father’s Name: Isidro N Cacanindin _______________________________

B. .(Full name)
Date and Place of Birth: 15 May 1971 / Brgy. Mucdol, Dipaculao, Aurora_ _

Address: Brgy. Mucdol, Dipaculao, Aurora _________ _ ___

Occupation and Place of Employment: Farmer__ _________

Citizenship: _Filipino_ if naturalized, give date and place where naturalized.

B. Mother’s Name: Marivic N Cacanindin _______________ ___

(Full Name)
Date and Place of Birth: 04 November 1969 / Brgy. Salay, Dipaculao, Aurora .

Address: Brgy. Mucdol, Dipaculao, Aurora __________________

Occupation and Place of Employment: _Housewife _____ __________

Citizenship: _Filipino__ if naturalized, give date and place where naturalized.

C. Brothers and Sisters

NAME AGE ADDRESS OCCUPATION

Andrrea Marie N 24 Brgy. Mucdol, Dipaculao, Medical Tech.
Cacanindin Aurora

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D. Step-parent or Guardian: N/A_____ ____ ______________________

Address: N/A __

Occupation and Place of Employment _ N/A ____________________

Citizenship ____ N/A ____if naturalized, give date and place where naturalized

E. Father-in-Law _ N/A ___ _____

Date and Place of Birth N/A _ _________ ___

Address: N/A __________ _________

(Street) (Bo/Brgy) (Town/City)
___ N/A __________ Tel Nr _______ N/A __
(Province)

Occupation and Place of Employment _N/A_ ____

Citizenship N/A____ If naturalized, give date and place where naturalized

F.Mother-in-Law__ N/A ____ _________

Date and Place of Birth _ N/A ___ _____

Address: _ N/A ____ _____

(Street) (Bo/Brgy) (Town/City)
___ N/A Tel Nr ___N/A____ _________
(Province)
Occupation and Place of Employment _ N/A _ _____

Citizenship _ N/A _ if naturalized, give date and place where naturalized

________________________________N/A___ ___________________________

V. EDUCATIONAL BACKGROUND

A. Elementary
School Location Date of Year Graduated
Attendance
Mucdol Elementary Brgy. Mucdol,
School Dipaculao, 1997 2003
Aurora

B. High School
School Location Date of Year
Attendance Graduated
Dipaculao National Brgy. Mucdol,
2003 2007
High School Dipaculao, Aurora

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(Formerly: Mucdol
National High School

C. College
School Course Location Date of Year
Attendance Graduated
Southeast Asian
College Inc.
(Formerly:
BS Nursing Quezon City 2008 2011
United Doctors
Medical
College)

D. Post Graduate
School Course Location Date of Year
Attendance Graduated
N/A N/A N/A N/A N/A

E. Other Schools Attended and Date of Attendance

School Course Location Date of Year
Attendance Graduated
N/A N/A N/A N/A N/A

F. Civil Service Eligibility, if any, and others similar qualifications ____ N/A ___ _ __

VI. MILITARY HISTORY

A. Date Enlisted in the AFP _12 June 2012 _____ ____________ _____
B. Date of Commission ___N/A____ Source of Commission _____N/A___ __ __ _
C. Important Unit Assignment since Enlistment/CAD: CGDNM/CGS MISOR________
D. Military Schools Attended

Name of Schools Date of Nature of Rating

&Location Attendance Training
NOBTC, CGETC, PCG 12 Dec 2012 6 Months 39 out of 183
N/A N/A N/A N/A

E. Decorations and Awards or Commendations Received

Type of Award(s) Authority

Award of Coast Guard Search and GO NR 12 HCGDNELZN DTD 28 JUNE
Rescue Medal 2017

Award of Coast Guard Merit Medal GO NR 102 HCGDNM DTD 27 DEC 2017
and Ribbon
Award of Coast Guard Merit Medal GO NR 101 HCGDNM DTD 27 DEC 2017
and Ribbon

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Award of Coast Guard Merit Medal GO NR 095 HCGDNM DTD 18 DEC 2017
and Ribbon
Award of Coast Guard Merit Medal GO NR 09 HCGDNELZN DTD 28 JUNE
and Ribbon 2017

Award of Coast Guard Merit Medal GO NR 11 HCGDNELZN DTD 28 JUNE

and Ribbon 2017

Award of Coast Guard GO NR 010 HCGDNELZN DTD 28 JUNE

Commendation and Ribbon 2017

Award of Coast Guard Civic Action GO NR 08 HCGDNELZN DTD 28 JUNE

Ribbon 2017

Award of Coast Guard Search and GO NR 06 HCGDNELZN DTD 01 MAR

Rescue Medal 16

Award of Coast Guard Merit Medal GO NR 18 HCGDNELZN DTD 04 MAR

and Ribbon 16

Award of Coast Guard Merit Medal GO NR 19 HCGDNELZN DTD 04 MAR

and Ribbon 16

Award of Coast Guard Merit Medal GO NR 26 HCGDNELZN DTD 04 MAR

and Ribbon 16

Award of Coast Guard Civic Action GO NR 25 HCGDNELZN DTD 01 MAR

Ribbon 16

Award of Coast Guard Civic Action GO NR 07 HCGDNELZN DTD 01 MAR

Ribbon 16

Award of Coast Guard Civic Action GO NR 14 HCGDNELZN DTD 01 MAR

Ribbon 16

Award of Coast Guard Civic Action GO NR 14 HCGDNELZN DTD 14 OCT

Ribbon 15

Award of Coast Guard Civic Action GO NR 46 HCGDNELZN DTD 14 OCT

Ribbon 15

Award of Coast Guard Civic Action GO NR 49 HCGDNELZN DTD 14 OCT

Ribbon 15

Award of Coast Guard Civic Action GO NR 44 HCGDNELZN DTD 14 OCT

Ribbon 15

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Award of Coast Guard Merit Medal GO NR 93 HCGDNELZN DTD 30 SEP 14

and Ribbon
Award of Coast Guard Merit Medal GO NR 86 HCGDNELZN DTD 30 SEP 14
and Ribbon
Award of Coast Guard Civic Action GO NR 70 HCGDNELZN DTD 30 SEP
Ribbon 14

VII. PLACES OF RESIDENCE SINCE BIRTH

Inclusive Dates Places/Address

1990 - Present Brgy. Mucdol, Dipaculao, Aurora

VIII. EMPLOYMENT

Inclusive Type of Employment Name/Address of Reason of

Dates Employment Leaving
N/A N/A N/A N/A

Have you ever been dismissed or forced to resign from a position? Yes _ __ No ___
If yes, explain ____________N/A_______________ _____

IX. FOREIGN COUNTRIES VISITED (In chronological order)

Date Country Visited Purpose of Visit

N/A N/A N/A

X. CREDIT REPUTATION
A. Are you entirely dependent on your salary? Yes ____ No ______ if no, state
other sources of income ______N/A___________________ _____
B. Name and Address of Banks or other Credit/Institution with which your have
accounts/loans: _____Land Bank of the Philippines_______________ ___
C. Have you filed a statement of your Assets and Liabilities with any
government agency
Yes __ No _____ If so, what, agency? ___PCG________ __
D. Have you filed your last income tax return? _Yes __

E. Three (3) credit references in the Philippines:

Name Address
AFPMBAI Manila

PCGSLAI Manila

N/A N/A

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XI. ARREST RECORD AND CONDUCT

A. Have you ever investigated / arrested, indicted or convicted for any violation
of law?_No_? If so, state name of court, nature of offense and disposition of case.
__________________N/A_____________________________________ _______
D. Has any member of your family ever been investigated / arrested, indicated
or convicted for any violation of law? ___No_______ If so, state name of court,
nature of the case and disposition of case ___N/A____________________ ____
E. Have you, ever been charged in any Administrative Case? _____No_ ____
F. Have you ever been arrested or detained pursuant to the provision of PD
1081 and its implementation order (GO, PO, LOI)? _No__ If so, state the nature of
the case and the place of your detention ________N/A__________________ ____
G. Do you use intoxicating liquor or narcotics? ____No______ If so, what
extent? __________________N/A_______________________ _______
XII. GENERAL REPUTATION
A. Give five (5) character references (not relatives) known three years or longer,
who are not your relatives:

Name Business Address/Residence

(Include Street & Number)
Yurich A Lapsot Brgy. Mucdol, Dipaculao, Aurora
Kristine D Balageo Brgy. Mucdol, Dipaculao, Aurora
Zyrine DL Sarmiento Brgy. Mucdol, Dipaculao, Aurora
Roman Paolo A Pascua Brgy. North Poblacion, Dipaculao, Aurora
Rex R Montanez Brgy. Mucdol, Dipaculao, Aurora

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

Name Business Address/Residence

(Include Street & Number)
Paul Yves DL Cacanindin Brgy. Mucdol, Dipaculao, Aurora
Yurich A Lapsot Brgy. Mucdol, Dipaculao, Aurora
David A Mapangdol Brgy. Mucdol, Dipaculao, Aurora

XIII. ORGANIZATION

List of organization or social groups which you have been a member:

Organization Address Date of Membership &

Position held
N/A N/A N/A

XIV. MISCELLANEOUS

A. Hobbies, sports and past times

Online Gaming, Badminton, Table Tennis _____________ _____

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B. Language and Dialect (indicate ability as fluent, fair or poor):

Language or Dialect Speak Read Write

Tagalog Fluent Fluent Fluent
Ilocano Fluent Fluent Fluent
English Fair Fair Fair
N/A N/A N/A N/A

C. Are you willing to undergo periodic lie detection test? _____Yes_ ________

D. Copy exactly the following paragraph in your own handwriting

As Luis E Rapazo III of 105th Xavier Ave guzzled his way trhough
three bottles of brandy, Josephine Z Quinsing, a partner in 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 HadjiJairul 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.”
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I certify that the foregoing answers are true and correct to the best
of my knowledge and belief and I agree that my misstatement or omission as
to material facts will constitute ground for denial of my application for
clearance.

Signed at _______________________ Date _____________________

_________________________________
(Signature of Applicant)

___________________________ ____________________ _______

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(Witness) (Witness)

THUMBMARKS

LEFT RIGHT

Subscribed and sworn to before me this _______day of __ ______

Philippines, affiant exhibited to me his /her Community Certificate Nr __________
Issued on _ ____at ____________

CDR FERDINAND F MONTERMOSO PCG

(Administrative Officer/Notary Public)

Station Commander, CGS MISOR

_ _ _
(TIN)

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