APPLICANT’S PERSONAL HISTORY STATEMENT FORM
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: _________________________________________________________________________
(Last) (First) (Middle)
B. Rank: _________________ PCGSN: ______________ Br/Svc: ____________________________
C. Present Job / Assignment: __________________________________________________________
D. Business or Duty Address: _________________________________________________________
E. Home Address (Include St. & Nr): ___________________________________________________
F. Birth Date: ________________________ Place of Birth: ______________________________
G. Change in Name (If by Court Action give details): _________________ NOT APPLICABLE ___
H. Nicknames: _________________________ Nationality: __________________________
I. TIN: ________________________________ National Reg. Card: ___________________
J. Religion: ____________________________ Blood Type: _________________________
II. PERSONAL CHARACTERISTICS
A. Description: Sex: _______ Age:______ Height:_____ Weight______
Build (heavy, Medium, Light): ___________ Complexion (Dark, Fair, Light): ________________
Color of Eyes: ________________________ Color of Hair: ______________________________
Personal History Statement / 1 of 8
Scars or marks and other distinguishing features: __________________________________________
B. Physical Condition/Present State of health (Excellent, Good, Poor) _________________________
Physical or Mental Defects: _________________ Recent Serious Illness: ________________
III. MARITAL HISTORY
A. Marital Status: ___________________________________________________________________
(Single, Married, Separated or Widow)
B. Name of Spouse: _________________________________________________________________
(Full Name)
Date and Place of Marriage: ___________________________________________________________
Occupation and Place of Employment: __________________________________________________
C. Children:
Name Date Of Birth Citizenship
IV. FAMILY HISTORY AND INFORMATION
A. Father’s Name: (Full Name) ________________________________________________________
Date and Place of Birth: ___________________________________________________________
Address: ________________________________________________________________________
Occupation and Place of Employment: ________________________________________________
Citizenship: __________________________ (if naturalized, give date and place where naturalized)
B. Mother’s Name: (Full Name) _______________________________________________________
Date and Place of Birth: ___________________________________________________________
Address: ________________________________________________________________________
Occupation and Place of Employment: ________________________________________________
Citizenship: __________________________ (if naturalized, give date and place where naturalized)
C. Brothers and Sisters
Name Age Address Occupation
Personal History Statement / 2 of 8
D. Stepparent or Guardian: ___________________________________________________________
Address ________________________________________________________________________
Occupation and Place of Employment _________________________________________________
Citizenship __________________________ (if naturalized, give date and place where naturalized)
E. Father-in-Law: ___________________________________________________________________
Date and Place of Birth ______________________________________________________________
Address __________________________________________________________________________
(Street) (Bo/Brgy) (Town/City)
Province ____________________________________________ Tel Nr _________________
Occupation and Place of Employment ___________________________________________________
Citizenship_____________________________ (If naturalized, give date and place where naturalized)
F. Mother-in-Law: __________________________________________________________________
Date and Place of Birth ______________________________________________________________
Address __________________________________________________________________________
(Street) (Bo/Brgy) (Town/City)
Province ____________________________________________ Tel Nr _________________
Occupation and Place of Employment ___________________________________________________
Citizenship ____________________________ (if naturalized, give date and place where naturalized)
V. EDUCATIONAL BACKGROUND
A. Elementary
School Location Date of Attendance Year Graduated
High school
School Location Date of Attendance Year Graduated
College
School Course Location Date of Attendance Graduated
Personal History Statement / 3 of 8
Post Graduate
School Course Location Date of Attendance Graduated
E. Other Schools Attended and Date of Attendance
School Course Location Date of Attendance Graduated
F. Civil Service Eligibility, if any, and others similar qualifications ______________________________
VI. MILITARY HISTORY
A. Date Enlisted in the AFP: ___________________________________________________________
B. Date of Commission___________________ Source of Commission__________________
C. Important Unit Assignment since Enlistment/CAD: ______________________________________
__________________________________________________________________________________
D. Military Schools Attended
Name of school and location Date of attendance Nature of training Rating
E. Decorations and Awards or Commendations Received
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
VII. PLACES OF RESIDENCE SINCE BIRTH
Inclusive Dates Places/Address
Personal History Statement / 4 of 8
VIII. EMPLOYMENT
Name/Address of
Inclusive Dates Type of Employment Reason of Leaving
Employment
Have you ever been dismissed or forced to resign from a position? Yes ________ No _______
If yes, explain ______________________________________________________________________
IX. FOREIGN COUNTRIES VISITED (In chronological order)
Date Country visited Purpose of visit
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/Institution with which your 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. Have you filed your last income tax return? ____________________________________________
E. Three (3) credit references in the Philippines:
Name Address
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.___________________________
Personal History Statement / 5 of 8
B. Has any member of your family ever been investigated / arrested, indicated or convicted for any
violation of law? If so, state name of court, nature of the case and disposition of case.
__________________________________________________________________________________
C. Have you, ever been charged in any Administrative Case? Yes ___ No___
D. Have you ever been arrested or detained pursuant to the provision of PD 1081 and its
implementation order (GO, PO, LOI)? ___If so, state the nature of the case and the place of your
detention _________________________________________________________________________
E. Do you use intoxicating liquor or narcotics? _______ If so, what extent? ____________________
XII. GENERAL REPUTATION
A. Give five (5) character references (not relatives) known three years or longer, who are not your
relatives:
Business Address/Residence
Name (Include Street & Number)
B. List down three (3) neighbors at your present residence:
Business Address/Residence
Name (Include Street & Number)
XIII. ORGANIZATION
List of organization or social groups that you have been a member:
Date of Membership &
Organization Address
Position held
XIV. MISCELLANEOUS
A. Hobbies, sports and past times READING BOOKS
__________________________________________________________________________________
__________________________________________________________________________________
Personal History Statement / 6 of 8
B. Language and Dialect (indicate ability as fluent, fair or poor):
Language or Dialect Speak Read Write
C. Are you willing to undergo periodic lie detection test? ___________________________________
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 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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Personal History Statement / 7 of 8
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)
(Witness) (Witness)
THUMBMARK
Please paste here
2 X 2 colored photo
w/ WHITE BACKGROUND
FORMAL ATTIRE
LEFT RIGHT
Subscribed and sworn to before me this _____ day of _____________________, _________
Philippines, affiant exhibited to me his /her Community Certificate Nr _________________________
Issued on __________________________at ______________________________________________
_____________________________
Administrative Officer/ Notary Public
_____________________________
Rank & Designation
_____________________________
TIN
Reminder: DON’T FORGET TO NOTARIZE THIS FORM
Personal History Statement / 8 of 8
