CONFIDENTIAL

ANNEX A of AFPR G 200-054 dtd 28 May 2019

GHQ, OJ2 File Nr:

200-054 Form

PERSONNEL HISTORY STATEMENT

INSTRUCTIONS
1. Answer all questions completely; if 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 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 statements made herein are classified CONFIDENTIAL. Revelation or use other than
the authorized purpose is prohibited by AFPR G 200-054.

I. PERSONAL DETAILS

A. NAME:
(Last) (First) (Middle/Maternal)
B. RANK: AFPSN: BR/SVC:
__________________________

C. PRESENT JOB/ASSIGNMENT:
(Signature of Applicant)

D. BUSINESS OR DUTY ADDRESS:

E. HOME ADDRESS (Include street & number):

F. BIRTHDATE: PLACE:

G. CHANGE IN NAME (If by Court Action, give details):

H. NICKNAMES: NATIONALITY:

I. TAX IDENTIFICATION NR: TEL NO.

J. MOBILE PHONE NR: _____________________ E-MAIL ADDRESS: _________________

K. PASSPORT NR: _________________________ DATE OF EXPIRATION:

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ANNEX A of AFPR G 200-054 dtd 28 May 2019 cont’n:

II. PERSONAL CHARACTERISTICS:

A. DESCRIPTION: Sex: Age: Height: (M) Weight: (kgs)

Build (Heavy, Medium, Light):
Complexion (Dark, Fair, Light): Color of Eyes:
Color of Hair: Scars or Marks & Other Distinguishing Features:

B. PHYSICAL CONDITION:

Present State of Health (Excellent, good, Poor):

Recent Serious Illness:

Blood Type:

III. MARITAL HISTORY

A. MARITAL STATUS:
(Single, Married, Separated or Widowed)
B. NAME OF SPOUSE:
(Full Name)
Date & Place of Marriage:

Date of Birth: Place of Birth:

Occupation & Place of Employment:

__________________________

Contact Number: Citizenship: if dual,

(Other Citizenship)
(Signature of Applicant)

C. CHILDREN:

Name Date of Birth Citizenship/Address Name of

Father/Mother

(Use back page for additional information)

IV. FAMILY HISTORY AND INFORMATION:

A. FATHER:
(Full Name)
Date & Place of Birth

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ANNEX A of AFPR G 200-054 dtd 28 May 2019 cont’n:

Complete Address:

Occupation/Employer/Place of Employment:

Citizenship: If dual, write both citizenship. If naturalized, give date

and place where naturalized

B. MOTHER:
(Full Name)
Date & Place of Birth
Complete Address:

Occupation/Employer/Place of Employment:

Citizenship: If dual, write both citizenship. If naturalized, give date

and place where naturalized

C. BROTHERS AND SISTERS:

CITIZENSHI
NAME DATE OF P (IF DUAL, COMPLETE ADDRESS OCCUPATIO EMPLOYER/
BIRTH WRITE N ADDRESS
BOTH)
__________________________

D. STEP-PARENT OR GUARDIAN:
(Full Name)
(Signature of Applicant)

Date & place of Birth

Complete Address:

Occupation/Employer/Place of Employment:

Citizenship: If dual, write both citizenship. If naturalized, give date

and place where naturalized

E. FATHER-IN-LAW:
(Full Name)
Date & Place of Birth

Complete Address:

Occupation/Employer/Place of Employment:

Citizenship: If dual, write both citizenship. If naturalized, give date

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and place where naturalized

ANNEX A of AFPR G 200-054 dtd 28 May 2019 cont’n:

F. MOTHER-IN-LAW:
(Full Name)

Date & Place of Birth

Complete Address:

Occupation/Employer/Place of Employment:

Citizenship: If dual, write both citizenship. If naturalized, give date

and place where naturalized

V. EDUCATIONAL BACKGROUND

A. Elementary Location Date of Year

Attendance Graduated

B. High School Location Date of Year

Attendance Graduated

B. College Location Date of Course Taken/

Attendance Year Graduated
__________________________
(Signature of Applicant)

C. Post Graduate Location Date of Course Taken/

Attendance Year Graduated

E. Other Schools/Training Attended and Date of Attendance:

F. Civil Service Eligibility, If any and Other Similar Qualifications Acquired:

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ANNEX A of AFPR G 200-054 dtd 28 May 2019 cont’n:

VI. MILITARY HISTORY:

A. Date Enlisted in the AFP:

B. Date of Commission:

C. Source of Commission:

D. Important Unit Assignments since Enlistment/CAD:

INCLUSIVE DATES UNIT/OFFICE CHIEF OF OFFICE

__________________________
(Signature of Applicant)

E. Military Schools Attended:

School/Location Date of Nature of Rating

Attendance Training

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ANNEX A of AFPR G 200-054 dtd 28 May 2019 cont’n:

F. Decorations, Awards or Commendations Received:

(Use additional sheets if necessary)

VII. PLACES OF RESIDENCE SINCE BIRTH:

Inclusive Dates Address

__________________________

VIII. EMPLOYMENT:
(Signature of Applicant)

Inclusive Type of Name & Address Reason for

Date Employment of Employer Leaving

Have you ever been dismissed or forced to resign from a position: No ( ) Yes ( ) If yes, explain

IX. FOREIGN COUNTRIES VISITED:

Date of Visit Country Visited Purpose of Visit Address Abroad

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ANNEX A of AFPR G 200-054 dtd 28 May 2019 cont’n:

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 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. Have you filed your latest Income Tax Returns?

Amount paid for the last Calendar Year:

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

Name Address

XI. ARREST RECORD AND CONDUCT:

A. Have you ever been investigated/arrested, indicted or convicted for any violation of law?
Yes ( ) No ( ). If so, state name of court, nature of offense and disposition of case.

B. Has any member of your family been investigated/arrested, indicted or convicted for any
__________________________

violation of law? Yes ( ) No ( ). If so, state name of court, nature of offense and disposition of case.
(Signature of Applicant)

C. Have you ever been charged of any administrative case? Yes ( ) No ( ) If so, explain:

D. Have you ever been arrested or detained pursuant to the provisions of PD 1081 and it’s
implementing orders (GO, PD, LOI)? Yes ( ) No ( ) If so, state the nature of the case and the place of
your detention.

E. Do you use intoxicating liquor or narcotics? Yes ( ) No ( ) If so, to what extent?

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XII. GENERAL REPUTATION:

A. Give five (5) character references (known three years or longer, who are not your
relatives):

Name Address

ANNEX A of AFPR G 200-054 dtd 28 May 2019 cont’n:

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

Name Address

XIII. ORGANIZATIONS:

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

Organization Address Date of Position

Membership Held

XIV. MISCELLANEOUS:

D. Hobbies, sports and past times.

E. Language and dialects (indicate ability as fluent, fair or poor):

__________________________

Language/Dialect Speak Read Write

(Signature of Applicant)

F. Are you willing to undergo periodic lie detector test?

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

As Luis E Rapazo III of 105 th 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
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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 speak for my government but I’m quite sure your country
and mine better get together for closer understanding.”

ANNEX A of AFPR G 200-054 dtd 28 May 2019 cont’n:

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 a material fact will constitute
ground for immediate denial of my application for clearance.
Signed at: Date:

(Witness) (Signature of Applicant)

(Witness)

THUMB MARKS:

2x2 Photo

(Left) (Right)

SUBSCRIBED AND SWORN to before me this ________ of

Philippines, Affiant exhibited to me his/her Community Tax Certificate Nr.
issued at on .

__________________
__________________
__________________

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ANNEX A of AFPR G 200-054 dtd 28 May 2019 cont’n:

SKETCH YOUR RESIDENCE ADDRESS

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__________________________
(Signature of Applicant)

ANNEX B of AFPR G 200 - 054

REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF NATIONAL DEFENSE
GENERAL HEADQUARTERS, ARMED FORCES OF THE PHILIPPINES
Camp General Emilio Aguinaldo, Quezon City

SECURITY DECLARATION

(To be read and signed by all military personnel, employees and research contract personnel.)

I, ___________________________________, of legal age, (employed, assigned or under

contract) of __________________ do hereby declare or affirm:

1. That I shall be responsible for preserving the security of all classified information which
may be imparted to me as a result of my employment/training/research with the Armed Forces of the
Philippines and undertake to comply with such regulations concerning security as may from time to be laid
down;

2. That I shall not divulge any classified information gained by me as a result of my

employment/training/research to any unauthorized person, either in verbal or written form;
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3. That I shall not, without authority of the Chief of Staff, Armed Forces of the Philippines,
now or in the future , publish any classified information which I have acquired or to which I have had access
owing to my employment/training/research in the _____________whether orally or in
any document, article, book, play, film or otherwise;

4. That on leaving the _____________________ I shall surrender any sketch, plan, model,
article, note, security tag/badge or document, hard or soft copy, made or acquired by me in the course of
my official duties/training/research, declared to be classified material/information, same such as I have
been duly authorized to retain by the _____________________.

5. That failure on my part to safeguard classified information can make me liable to lose my
security clearance to prosecution under the Revised Penal Code and Commonwealth Act 616, and to be
declared as security risk.

I hereby certify that I have read and fully understood AFPR G 200-014 and I am aware of
Responsibilities of safeguarding Armed Forces classified information.

I fully understand that the provisions of this Security Declaration apply not only during the period of
my employment/training/research, but also after my employment/training/research with the AFP shall have
ceased, that I am liable to prosecution under the Revised Administrative Code, Commonwealth Act 616
and other existing laws, regulations of the Republic of the Philippines, if either by intent or negligence, I
allow classified information to pass into unauthorized hands.

____________________________________
SIGNATURE OVER PINTED NAME

SUBSCRIBED AND SWORN TO BEFORE ME ON THIS_______DAY OF _____________20_

_.

____________________
____________________
Copy furnished ____________________
1 – Security Officer
2 – Concerned Individual

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