PERSONNEL HISTORY STATEMENT

INSTRUCTIONS
1. Answer all questions completely; if questions are not applicable write "NA", write "UNKNOWN" only if you do not know he 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 from which you do not have sufficient space. 2. Type, print or write carefully, illegible or incomplete form will not receive consideration.

WARNING
1. The corrections to all statements or entries made herein will be investigated. 2. Type, print or write carefully, illegible or material facts may give sufficient cause for denial of clearance. 3. That statements made herein are classified CONFIDENTIAL. Revelation or use of other than the authorized purpose is prohibited.

I.

PERSONAL DETAILS:
FIRST NAME: MAIDEN NAME: POB: RELIGION: MIDDLE NAME: CIVIL STATUS:

LAST NAME: NICKNAME: DATE OF BIRTH: HOME ADDRESS: (Hse Nr/St/Brgy/Bo) TOWN/MUN/CITY OR PROV: HOME TEL NR: POSITION / DESIGNATION: UNIT / OFFICE: DATE OF MARRIAGE: TIN: EMPLOYEES ID NR:

OCCUPATION: TEL NR: OFFICE ADDRESS:

NATIONALITY: CITIZENSHIP:

PLACE OF MARRIAGE: CHANGE OF NAME: GSIS POLICY NR: ETHNIC/TRIBAL GRP:

II.
SEX: HAIR:

PERSONAL CHARACTERISTIC:
AGE: WEIGHT:(2.2/KGS) BLOOD TYPE: BUILD: COMPLEXION: EYES: HEIGHT: (2.54/CMS)

PHYSICAL CONDITION: DISTINGUISING FEATURE:

RECENT SERIOUS ILLNESS:

III.

MARITAL HISTORY:
MIDDLE NAME: POB: OFFICE ADDRESS: NATIONALITY: NICKNAME: TEL NR. DATE NATURALIZED:

SPOUSE NAME: DATE OF BIRTH: HOME ADDRESS: OCCUPATION: OFFICE TEL NR: PLACE OF NATURALIZED:

CHILDREN / DEPENDENTS : ( USE BACK SPACE FOR MORE DATA )

NAME DATE OF BIRTH ADDRES AGE:

PERSONNEL HISTORY STATEMENT

IV.

FAMILY HISTORY AND INFORMATION

NATIONALITY: POB: CITIZENSHIP: OCCUPATION: TEL NR. TEL NR. CITIZENSHIP: OCCUPATION: TEL NR. TEL NR. CITIZENSHIP: OCCUPATION: TEL NR. TEL NR. CITIZENSHIP: OCCUPATION: TEL NR. TEL NR. CITIZENSHIP: OCCUPATION: TEL NR. TEL NR.

FATHER DATE OF BIRTH: HOME ADDRESS: PLACE OF EMPLOYMENT: MOTHER DATE OF BIRTH: HOME ADDRESS: PLACE OF EMPLOYMENT: GUARDIAN DATE OF BIRTH: HOME ADDRESS: PLACE OF EMPLOYMENT: FATHER IN LAW DATE OF BIRTH: HOME ADDRESS: PLACE OF EMPLOYMENT: MOTHER IN LAW DATE OF BIRTH: HOME ADDRESS: PLACE OF EMPLOYMENT:

NATIONALITY: POB:

NATIONALITY: POB:

NATIONALITY: POB:

NATIONALITY: POB:

BROTHERS AND SISTERS : ( USE BACK SPACE FOR MORE DATA )

NAME AGE: MARITAL STATUS ADDRES OCCUPATION:

V.

EDUCATIONAL BACKGROUND
NAME OF SCHOOL LOCATION INCLUSIVE DATE DEGREE EARNED

A.

ELEMENTARY

B.

HIGH SCHOOL

C.

COLLEGE

PERSONNEL HISTORY STATEMENT

D. POST GRADUATE

E.

OTHER SCHOOL / TRAINING ATTENDED: TRAINING COURSES INCLUSIVE DATE CONDUCTED BY

F.

ELIGIBILITY CIVIL SERVICE ELIGIBILITY / BOARD / BAR DATE OF EXAM RATING PLACE OF EXAM

VI.

EMPLOYMENT HISTORY:
AUTHORITY OF ENTRY TO SERVICE:

DATE ENTERED SERVICE:

SERVICE RECORDS: ( USE BACK SPACE FOR MORE DATA )

INCLUSIVE DATE POSITION DEPARTMENT / AGENCY SALARY STATUS OF APPMT

PRESENT DESIGNATION:
POSITION OFFICE DATE REMARKS Primary Secondary Tertiary

SIGNIFICANT POSITIONS HELD:

POSITION / DESIGNATION DEPARTMENT / AGENCY DATE FROM DATE TO

PERSONNEL HISTORY STATEMENT

AWARDS/DECORATIONS/COMMENDATIONS: ( USE BACK SPACE FOR MORE DATA )
AWARDS/DECORATIONS/COMMENDATIONS DATE AWARDED AUTHORITY

OTHER COURSES/TRAINING/SEMINARS ATTENDED (GOVERNMENT/CIVILIAN):

COURSE NAME OF SCHOOL INCLUSIVE DATE STANDING

SPECIAL SKILLS

OTHER QUALIFICATIONS:

LANGUAGE /DIALECTS:
LANGUAGES /DIALECTS SPEAK READ WRITE

VII.

ORGANIZATION: ( USE BACK SPACE FOR MORE DATA )

ORGANIZATION NAME ADDRESS DATE OF MEMBERSHIP POSITION HELD

VIII. PLACE OF RESIDENCE SINCE BIRTH: ( USE BACK SPACE FOR MORE DATA )
PLACE OF RESIDENCE INCLUSIVE DATES

PERSONNEL HISTORY STATEMENT

IX. COUNTRIES VISITED: ( USE BACK SPACE FOR MORE DATA )
COUNTRY PURPOSE OF VISIT DURATION

X.

ARREST RECORDS AND CONDUCT:

EVER BEEN ARRESTED? NO YES ANY RELATIVE ARRESTED? NONE YES ANY ADMINISTRATIVE CASE? NO YES VIOLATION OF PD 1802? NO YES NARCOTIC OR LIQUOR USE? NO YES ARE YOU WILLING TO UNDERGO PERIODIC LIE DETECTION TEST? NO

YES

XI.

ARREST RECORDS AND CONDUCT:

CHARACTER REFERENCES
LENGTH OF ACQUAINTANCE

NAME

BUSINESS ADDRESS

OCCUPATION

NEIGHBORS AT PRESENT RESIDENCE:

NAME BUSINESS ADDRESS

XII.

CREDIT REPUTATION:
NO NO

ARE YOU DEPENDENT ON YOUR SALARY? YES OTHER SOURCES OF INCOME? YES NO HAVE YOU FILE YOUR ASSET AND LIABILITIES? YES WHAT AGENCY? YES NO HAVE YOU FILE YOUR ITR? YES NO AMOUNT PAID

CREDIT REFERENCES:
NAME BUSINESS ADDRESS

PERSONNEL HISTORY STATEMENT

XIII. HANDWRITING SPECIMEN:
" Our London business is good but Vienna and Berlin are quite Mr. D. Lloyd has gone to Switzerland and I hope for good news. He will be there for a week at 1946 Zermett St. and then goes to Turne and Rome and join COL Perry and arrive at Athens Greece Nov 28th of Dec 2nd. Letters there should be addressed King James Blvd., 3589. We expect Chas E. Fueller Tuesday. Dr L. Mc Quiad and Robt; Under Ec, left on the Y. X. Express tonight."

I certify that the foregoing answers are true to the best of my knowledge and belief and I agree that misstatement or commission as to material fact will be for immediate denial of my application. Signed at Date:

(Witness)

(Witness)

(Signature) Left thumbmark Right thumbmark

Photo (2 x 2)

Subscribed and sworn to before me this ________ day of ________________________20 ___ at Bureau of Immigration, Intramuros, Manila, Philippines, and affiant exhibiting to me his / her Residence Certificate Nr _______________ issued at __________________________ on ____________________________.

Administering Officer