CONFIDENTIAL

ZXCGHQ B2 FILE NR____

200-053
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 blank
pages at the back of this form for extra details on any question for what 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 statements made herein are classified “CONFIDENTIAL”. Revelation or use for purposes other
than that authorized is prohibited by pertinent provisions of AFPR G 200-052.

I. PERSONAL DETAILS:

A. Name: Malooy__________ Ronan Roy________Bonggot_________________________

(Last) (First) (Middle)

B. Rank: SN1 AFPSN: 014551_________ Br/ Svc: Philippine Coast Guard_________________

C. Present Job/ Assignment: CoastGuard Sub-Station Baganga Davao Oriental________

E. Home Address (Include St. & Nr):2166 Santo Nino Street Mati City Davao Oriental.

F. Birth Date:18 August 1990 _______ Place of Birth:Mati City ______________________

G. Change In Name(If by Court Action give Details: N/A ____ _ _

H. Nicknames: Ron__________Nationality: Filipino________________________________

I. TIN:341-401-172____________Philhealth No:16-025812709-6___________________________

J. Religion: Roman Catholic_______Blood Type: A+______________________________________

K. Celphone/ Telephone Number: 09627514987_________________________________________

II. PERSONAL CHARACTERISTICS:

A. Description:

Sex:Male________________Age: 34_____Height: 175 (cms) Weight:80 (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: Mole on the tip of nose___________________
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B. Physical Condition:

Present State of Health (Excellent, Good, Poor): Excellent________________________

Physical or Mental Defects:N/A________ Recent Serious Illness: N/A______________

III. MARITAL STATUS:

A. Marital Status : Single __________ _______________________________

(Single, Married, Separated or Widow)

B. Name of Spouse: N/A_________________________________________________________

Date and Place of Marriage: _N/A______________________________________________

Occupation and Place of Employment: N/A_______________________________________

C. Children:

Name Date of Birth Citizenship

Castiel Roy Malooy 07 February 2023 Filipino

IV. FAMILY HISTORY AND INFORMATION:

A. Father’s Name: Aristedes A. Malooy___________________________ _______

(Full Name)

Date and Place of Birth: __15 August 1952/Mari City Davao Oriental.______________

Address: 2166 Santo Nino Street Mati City Davao Oriental____________________

Occupation and Place of Employment: ___Retired_____________________ ____

Citizenship: Filipino If naturalized, give Date and Place where naturalized: N/A _

B. Mother’s Name: Gerondia B Malooy ____________________________

(Full Name)

Date and Place of Birth: __25 May 1956/Mati City Davao Oriental._______________________

Address: 2166 Santo Nino Street Mati City Davao Oriental__________

Occupation and Place of Employment: _House wife__________ _______

Citizenship: Filipino If naturalized, give Date and Place where naturalized: N/A _____

C. Brothers and Sisters:

Name Age Address Occupation

Aris B Malooy 42 Mati City Davao Oriental Layout Designer
Ian Vincent B Malooy 41 Mati City Davao Oriental Deceased
Neil B Malooy Mati City Davao Oriental Nurse
Jonas B Malooy Mati City Davao Oriental Seaman
Katrina M Lim Mati City Davao Oriental Homebase Teacher
Jed William B Malooy Mati City Davao Oriental Fireman
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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. _N/A _

E. Father-In-Law: N/A ________________

Date and Place of Birth: N/A _______________________ __

Address: N/A

Occupation and Place of Employment: _________N/A_________________

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

F. Mother-In-Law: N/A _____ ___

Date and Place of Birth: ____N/A____________________________________________

Address: ______________N/A____________

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
Immaculate Heart of Mary Mati City, Davao 1997-2003 2003
Academy Oriental

B. High School:

School Location Date of Year Graduated

Attendance
Mati National Comprehensive Mati City Davao Oriental 2003-2007 2007
High School

C. College:

School Course Location Date of Year

Attendance Graduated
University of the Bachelor Of Bangkerohan, 2007-2011 2011
Immaculate Concepcion Science in Davao City
Pharmacy

D. Post Graduate:

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

E. 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 other similar qualification acquired: N/A_

VI. MILITARY HISTORY:

A. Date Enlisted in the PCG:_30 April 2019_________

B. Date of Commission: N/A Source of Commission: N/A __

C. Important Unit Assignments Since Enlistment/CAD:

INCLUSIVE
UNIT DUTY / POSITION PERIOD AUTHORITY
(From – To)
19
December
SO Nr 020 HCGDSEM dtd 29
HCGDSEM DSG 2019 – 24
December 2019
January
2020
24 January
2020 – 12 SO Nr 126 NHQ PCG dtd 30 June
Medical-SEM Swabber
August 2020
2021
12 August
SO Nr 008 HCGDSEM dtd 30 August
HCGDSEM D3 2021 – 03
2021
April 2022
03 April
CGS Davao 2022 – 20 SO Nr 019 HCGDSEM dtd 21 March
S3
Oriental September 2022
2022
20
September SO Nr 27 CGS Davor dtd 39
CGSS Lupon Member
2022- 28 September 2022
July 2023
28 July
2023 – 30 SO Nr 31 CGS Davor dtd 28 July
CGSS Boston Member
November 2023
2024
30
CGSS November So Nr 24 CGS Davor dtd 30
Assistant Subcom
Baganga 2024 – November 2024
Present

D. Military Schools Attended:

Name of School & Location Date of Attendance Nature of Training Rating
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N/A N/A N/A N/A

E. Decorations, Awards or Commendation Received

Type of Award(s) Authority
Coast Guard Search and Rescue Medal HCGDSEM GO No. 012 dtd January 2024
Coast Guard Commendation Medal and HCGDSEM GO No. 003 dtd January 2024
Ribbon
Coast Guard Merit Medal and Ribbon HCGDSEM GO No. 017 dtd January 2024
Coast Guard Disaster Relief Operation and HCGDSEM GO No. 016 dtd17 March 2022
Rehabilitation Operation Ribbon
Coast Guard Merit Medal and Ribbon HCGDSEM GO No. 015 dtd 17 March 2024
Coast Guard Commendation Medal and HCGDSEM GO No. 59 dtd 30 May 2021
Ribbon
Coast Guard Search and Rescue Medal HCGDSEM GO No. 14 dtd 11 March 2021
Coast Guard Merit Medal and Ribbon HCGDSEM GO No. 20 dtd 11 March 2021
Coast Guard Merit Medal and Ribbon HCGDSEM GO No. 51 dtd 22 May 2021
Coast Guard Merit Medal and Ribbon HCGDSEM GO No. 085 dtd 02 December
2021
Coast Guard Merit Medal and Ribbon HCGDSEM GO No. 075 dtd 27 August 2020
Coast Guard Merit Medal and Ribbon HCGDSEM GO No. 064 dtd 12 July 2020
Coast Guard Merit Medal and Ribbon HCGDSEM GO No. 082 dtd 20 August 2021
Coast Guard Civic Action HCGDSEM GO No. 019 dtd 17 March 2020

VII. PLACE OF RESIDENCE SINCE BIRTH:

Inclusive Dates Places/Address

1990 - Present 2166 Santo Nino Street Mati City Davao Oriental.

VIII. EMPLOYMENT:
Inclusive Dates Type of Name/Address of Reason for
Employment Employment Leaving
N/A N/A N/A N/A
N/A N/A N/A N/A

Have you ever been dismissed or forced to resign from a position? Yes _N/A___ No ___N/A

If yes, explain _______ N/A ____________________________________________

IX. FOREIGN COUNTRIES VISITED (In chronological order)

Date Country Visited Purpose of Visited

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 _________________________________________

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B. Names and Address of Banks or Other Credit/Institutions with which your have

accounts/loans: ACDI Coop_______________________________________

C. Have you filed a statement of your Assets and Liabilities with any government agency Yes

___/__ No _________ If so, what agency? __________DOTr-PCG __

D. Have you Filed your income tax return? ___ Yes ___

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

Name Address
N/A N/A
N/A N/A

XI. ARREST RECORD AND CONDUCT:

A. Have you ever been investigated/ arrested, indicated or convicted for any violation of Law?
__NO__ If so, state name of court, nature of offense and disposition of case._N/A__
B. 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 offense and disposition
of case.
C. Have you ever been charged in any Administrative Case? ___No___ If so, explain __
__________________ N/A_____________________________________________
D. Have ever been arrested or detained pursuant to the provisions of PD 1081 and its
implementation orders (GO,PO, LOI)? ___No_ __ If so, state the nature of case and the place
of your detention _____N/A____________________________________________.
E. Do you use intoxicating liquor or narcotics_No____ _ __ If so, to what extent? __N/A___

XII. GENERAL REPUTATION:

A. Give five (5) character reference (not relatives) known three years or longer, who are not
your relatives:
Name Business Address/Residence
(Include Street/Number)
Rebica Sibunga Mati City Davao Oriental
Clarita Dizon Mati City Davao Oriental
Leo Sanchez Mati City Davao Oriental
Jean Tagon Mati City Davao Oriental
Alexandra Vizmanos Mati City Davao Oriental

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

Name Business Address/Residence

(Include Street/Number)
Ian Maglimong Mati City Davao Oriental
Joseph Espinosa Mati City Davao Oriental
Zandro Rojas Mati City Davao Oriental

XIII. ORGANIZATION:

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

Organization Address Date of Membership &

Position
N/A N/A N/A

XIV. MISCELANEOUS

A. Hobbies, sports and past times

Playing Basketball, Playing Mobile Games and Playing Badminton

B. Language and Dialect (indicate ability as Fluent, Fair or Poor)

Language or Dialect Speak Read Write

Filipino Fluent Fluent Fluent
English Fair Fair Fair

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

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D. 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 Jairul 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 may misstatement or omission as to material facts will constitute ground for denial of my
application for clearance.

Signed at Coast Guard District Southeastern Mindanao Date:_ ___

__________________________
(Signature of Applicant)

______________________ __________________________
(Witness) (Witness)

LEFT RIGHT

Subscribed and sworn to before me this ____ day of ____________, _____ Philippines, affiant
exhibited to me his/her Community Certificate Nr. ____________
Issued on __________ at Davao City, Philippines.

PRIM ROSE Q GREGORIO

(Administrative Officer/Notary Public)

CG ENS/OIC, DS of DS for HRM, D-1

(Rank &Designation)

335-154-356
(TIN)

CONFIDENTIAL