CONFIDENTIAL

PERSONAL HISTORY STATEMENT

HPA FILE NR:

INSTRUCTIONS

1. ANSWER ALL QUESTIONS COMPLETELY. IF THE QUESTION IS NOT

APPLICABLE, WRITE “NA”. WRITE “UNKNOWN” ONLY IF YOU DO NOT KNOW THE

ANSWER AND CAN NOT OBTAIN FROM PERSONAL RECORDS. USE THE BLANK

PAGES AT THE BACK OF THIS FORM FOR EXTRA DETAILS OF THE ANSWERS TO

QUESTION FOR WHICH YOU DO NOT HAVE SUFFICIENT SPACE.

2. TYPE, PRINT OR WRITE CAREFULLY. ILLEGIBLE OR INCOMPLETE FORMS

WILL NOT RECEIVE CONSIDERATIONS.

WARNING

1. THE CORRECTNESS OF ALL STATEMENTS OR 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 OTHER THAN THE AUTHORIZED PURPOSE IS PROHIBITED

BY AFPR G 200-053.

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 CONFIDENTIAL

I. PERSONAL DATA:

A. Name: _
(Last) (First) (Middle/Maternal)
B. Rank: AFPSN: Br of Svc: _
C. Present Job Title/Assignment: _
D. Business or Duty Address: _
E. Home Address: _
(Include Street and District)
F. Date of Birth: Place of Birth: _
G. Change in Name: (If court action, give details): _
H. Nicknames: _
National Registry Nr: TIN: _
Religion: Blood Type: _
GSIS/SSS Nr: Tel Nr/CP Nr ________________________

II. PERSONAL CHARACTERESTICS:

A. Description: Sex: Age: Height: (meter)

Weight: (kgs) Built: (Heavy, Medium, Slight) _
Complexion (Dark,Fair, Light): Color of Eyes: _
Color of Hair: Scars or Marks and other distinguishing features: _
_
B. Physical Condition:
Present State o Health: (Excellent, Good, Poor): _
Physical or Mental Defects: _
Recent Serious Illness: _

III. MARITAL HISTORY:

A. Marital Status: _
(Single, Married, Separated or Widowed)
B. Name of Spouse: _
(Full Name)
Date of Marriage: _
Spouse Date of Birth: _
Spouse Place of Birth: _
Occupation and Place of Employment: _
Citizenship:__________If naturalized, give date and place where naturalized: _
_____________

C. Children:

Name Date of Birth Address

___________________ _______________ _____________________________
___________________ _______________ _____________________________
___________________ _______________ _____________________________
___________________ _______________ _____________________________
___________________ _______________ _____________________________
___________________ _______________ _____________________________
(Use Separate Sheet for Additional Information)

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IV. FAMILY HISTORY AND INFORMATION:

A. Father: __
(Full Name)
Date/Place of Birth: __
Address: __
Occupation and Place of Employment: __
Citizenship: If naturalized, give date and place where naturalized: ______
___________________________________________________________________

B. Mother: __
(Full Name)
Date/Place of Birth: __
Address: __
Occupation and Place of Employment: __
Citizenship: If naturalized, give date and place where naturalized: ______
___________________________________________________________________

C. Brothers and Sisters:

Name Occupation Present Address

___________________ _______________ ______________________________
___________________ _______________ ______________________________
___________________ _______________ ______________________________
___________________ _______________ ______________________________
___________________ _______________ ______________________________

D. Step-Parent of Guardian: __
(Full Name)
Address: __
Date and Place of Birth: __
Occupation and Place of Employment: __
E. Father-in-Law: __
Address: __
Date and Place of Birth: __
Occupation and Place of Employment: __
F. Mother-in-Law: __
Address: __
Date and Place of Birth: __
Occupation and Place of Employment: __
G. Brothers and Sisters-in-Law

Name Occupation Present Address

___________________ _______________ ______________________________
___________________ _______________ ______________________________
___________________ _______________ ______________________________
___________________ _______________ ______________________________
___________________ _______________ ______________________________

V. EDUCATIONAL BACKGROUND:

A. Elementary

Name of School Location Date of Attendance

________________________ ____________________ ___________________
________________________ ____________________ ___________________

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B. High School

Name of School Location Date of Attendance

________________________ ____________________ ___________________
________________________ ____________________ ___________________

C. College

Name/Location of School Date of Attendance Course/Yr Gradtd

________________________ ____________________ ___________________
________________________ ____________________ ___________________

D. Post Graduate
________________________ ____________________ ___________________
________________________ ____________________ ___________________
E. Other Schools Attended

Name of School Location Date of Attendance

________________________ ____________________ ___________________
________________________ ____________________ ___________________

F. Civil Service Eligibility, if any and other similar qualifications acquired:

__________________________________________________________________
__________________________________________________________________

VI. MILITARY HISTORY:

A. Date Entered Mil Svc (as Trainee or as Cadet) __

B. Date Enlisted: __
C. Date Commissioned: __
Source of Commission: __
D. Date of CAD: __
E. Have you ever been separated from the Military Service? __
If yes, state nature and circumstances: __
F. Important Duty Assignment:

Designation Inclusive Date Unit

___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________ __________________
___________________ __________________
___________________ __________________
___________________ __________________
___________________ __________________
___________________ __________________

G. Military Schools/Training attended/undergone:

Name/Location of School Inclusive Dates Course

___________________________ ___________________ _________________
___________________________ ___________________ _________________
___________________________ ___________________ _________________
___________________________ ___________________ _________________
___________________________ ___________________ _________________
___________________________ ___________________ _________________
(Use Separate Sheet for Additional Information)

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H. Awards, Commendation or Decorations received:

Awards/Decorations/Commendations Authority
_______________________________________ __________________________
_______________________________________ __________________________
_______________________________________ __________________________
_______________________________________ __________________________
_______________________________________ __________________________
_______________________________________ __________________________
(Use Separate Sheet for Additional Information)

VII. PLACES OF RESIDENCE SINCE BIRTH:

Complete Address Inclusive Dates

_______________________________________ _______________________________
_______________________________________ _______________________________
_______________________________________ _______________________________

VIII. EMPLOYMENT HISTORY:

Name/Address of Position Reason for Leaving Inclusive Dates

Employer
___________________ ______________ __________________ ________________
___________________ ______________ __________________ ________________
___________________ ______________ __________________ ________________

IX. FOREIGN COUNTRIES VISITED:

Date Countries Visited Purpose of Visit

_________________ ___________________________ ________________________
_________________ ___________________________ ________________________
_________________ ___________________________ ________________________
_________________ ___________________________ ________________________

X. CREDIT REPUTATION:

A. Are you entirely dependent on your salary? Yes ___ No ____________

If NO, state other source of income: _____ __
B. Names and Addresses of Banks or other Credit Institutions with which you have
Accounts/Loans:
C. Have you filed a Statement of your Assets and Liabilities with any government
agency? Yes _________ No __________ If so, what agency? ______________
D. Three (3) Credit Reference in the Philippines:

Name of Person Complete Home Address

___________________________________ ______________________________
___________________________________ ______________________________
___________________________________ ______________________________

XI. ARTICLES OF WAR, CRIMINAL AND CIVIL RECORDS:

A. Have you ever been involved for any violation of the Articles of War, Revised Penal
Code (RPC), Civil Code and other Ordinances? Yes _____ No ______. If Yes,
state name of court, nature of offense, nature of involvement and disposition of
case.
___________________________________________________________________
___________________________________________________________________

B. Has any member of your family been involved of any violation as stated in para A?
Yes ____ No ____. If Yes, state name of court, nature of offense, nature of
involvement and disposition of case.
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___________________________________________________________________

C. Have you ever been charged in any administrative case? Yes ______ No ______
If so, explain ________________________________________________________

D. Have you ever been arrested or detained pursuant to PD 1081 and its implementing
orders (GO, PO, LOI)? Yes _____ No _____. If so, state the name of court,
nature of offense and place of detention.__________________________________
__________________________________________________________________

E. Do you use/drink intoxicating liquor/beer? Yes _____ No _____. If so, to what

extent? ____________________________________________________________
F. Do you use drugs or narcotics? Yes _____ No _____. If so, specify and to what
extent? ____________________________________________________________

XI. GENERAL REPUTATION:

A. Give five (5) character references (Known three (3) years or longer who are not
your relatives):
Full Name Complete Home Address
__________________________________________ _____________________________
__________________________________________ _____________________________
__________________________________________ _____________________________
__________________________________________ _____________________________
__________________________________________ _____________________________

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

Full Name Complete Home Address

__________________________________________ _____________________________
__________________________________________ _____________________________
__________________________________________ _____________________________
__________________________________________ _____________________________

XII. ORGANIZATIONS:

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

Name of Organization Position Held Date of Membership

_________________________________ ______________ _______________________
_________________________________ ______________ _______________________

XIII. MISCELLANEOUS:

A. Hobbies, Sports and Past Times:

__________________________________________________________________

B. Skills (such as driving, carpentry, shorthand, typing, designing, etc)

__________________________________________________________________

C. Languages/Dialects Spoken (Indicate ability as Fluent/Fair/Poor)

Language or Dialect Speak Read Write

_____________________________ ___________ ____________ ___________
_____________________________ ___________ ____________ ___________

D. Are you willing to undergo periodic lie detector test? Yes _______ No _________

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

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As Luis Repaso III of 105 th 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 Hairula Hussein Blvd., and said “I can’t speak for my
government, but I’m quite sure your country and mine will 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 the material fact will constitute ground
for immediate denial of my application for clearance.

Signed at __________________________________________ Date ________________

WITNESSES: _______________________________
(Signature of Applicant)
______________________________________
______________________________________
______________________________________

2 x 2 PICTURE
(PASSPORT SIZE)
RIGHT HAND
THUMB MARK

SUBSCRIBED AND SWORN to before me this ________ day of _______________20 ___

at ____________________________________________________________________________,
Philippines. Affiant exhibiting to me his/her Residence Certificate Nr ___________________
issued on ____________20_____ at ________________________________________________

_______________________________
(Administering Officer/Notary Public)
_______________________________
(Rank and Designation)
TIN: ___________________________

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SKETCH OF THE IMMEDIATE VICINITY OF RESIDENCE

(Indicate Prominent Points/References)

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