ANNEX II.

P
CGA APPLI
CATION
FORM
PHILIPPINE
COAST GUARD

AUXILIARY __
______
AUXILIARY
SQUADRON

MEMBERSH
IP
APPLICATI

ON( ) New
Enrollment (
) Reenrollment (
) Transfer
of Squadron

LAST NAME FI
RST NAME MI
DDLE NAME S
UFFIX GENDER
()
Male( ) FemaleO
THER NAMES

USED:HOME
ADDRESSMARI
TAL
STATUS( ) Sing
le ( ) Married (
) Separated( )
Widow/Widowe
rNAME OF SPO

USE NO. OF CH
ILDRENHEIGH
T WEIGHT COL
OR OF EYES C
OLOR OF HAIR
SCARS OR
MARKS AND
OTHER

DISTINGUISH
ING
FEATURES:SS
S/GSIS NO. D
ATE OF BIRTH
PLACE OF BIRT
HCITIZENSHI
P RELIGION BL

OOD TYPETEL.
NO. (HOME) TE
L. NO. (BUSINE
SS) MOBILE P
HONEEMAIL 1
EMAIL 2 FAX
NO.ACR NO. (I
F ALIEN) PASS

PORT NO./EXP
IRY DATE TYPE
OF VISA ISSU
ED TIN NO.

SECTION II

EDUCATIONA
L
BACKGROUND

College/PostGrad/Special
Studies

NAME OF
SCHOOL

DEGREES OBT
AINED INCLU
SIVE DATES
YEAR GRADU
ATED

(Attached
photocopies of
either the
transcript of
records, diploma or
PRC certificate)

SECTION III

EMPLOYMEN
T/OCCUPATI
ONAL BACKG
ROUND
( ) EMPLOYED
( ) OWN BUSI
NESS

COMPANY COM
PANY COMPAN
Y COMPANY
(Attached latest
employments
certification, SEC
Registration, Art.
Of Incorporation o
r DTI Registration)

FOR PAST OR
CURRENTLY IN
GOVERNMENT
POSITION

Please state
highest
Appointment/Elec

ted
OfficePosition/Pe
riod
Assumed:Nature
of Office:
(Attached
certification from
the Office
concerned)

SECTION IV

ADDITIONAL
DATA
PROFESSIONA
L
LICENCES:SPE

CIAL
TRAININGS:SP
ECIAL
INTERESTS/S
KILLS:
(Attached
photocopies of

license/s
or certificate/s)

MA

2009 Page 2 of
4 MEMBERSHI
P APPLICATIO
N

SECTION V

EMERGENCY
CONTACT
INFORMATI
ON

LAST NAME FI
RST NAME MI
SUFFIX RELAT
IONSHIPADDR
ESSTEL NO. (H
OME) TEL NO. (
BUSINESS) M

OBILE PHONE
NO.

SECTION VI

READINESS
INPUT

A.
FUNCTIONS
YOU WANTED
TO BE
INVOLVED IN:
(Please check
choice/s)( ) MA
RSAR


Maritime
Search and
Rescue( ) MARE
P

Marine
Environmental

Protection( ) M
ARSAF

Maritime
Safety( ) COMR
EL

Community
Relations (Civic
action activities
i.e.
Medical/Dental
Missions;Youth
development)B.
ANSWER B1

AND CHECK
APPROPRIATE
ANSWERS FOR
B2 TO B4:1.
What is your
purpose in
joining the
PCGA? (in at

least 50 words
you may use
separate
sheet)2. Are yo
u willing to be t
rained? ( ) Yes (
) No3. Are you
willing to travel

outside of your
home area? ( ) Y
es ( ) No4. Are
you available on
call 24 hours? (
) Yes ( ) No If
No, need _____

_days/advance
notice

SECTION
VII

ASSETS/RES
OURCES

AVAILABLE
TO PCGA
PROJECTS
(This data will
be used for
reference as
available
resources in

times of
disaster/emerge
ncy only and
does not mean a
full turn-over to
PCG/PCGA of
said
items/equipment)

ITEMS/CLASS
IFICATION Q
UANTITY DES
CRIPTIONWAT
ERCRAFT (Boat
) Name ______
____________
______ Type__

____________
______Speed_
____________
___________P
ower________
___________R
ange________
_____Full Capa

city (Ltrs/Gals)
____________
____AIRCRAF
TLAND
TRANSPORTAT
IONAMBULAN
CE/FIRETRUCK
SOTHER

EQUIPMENTS
(Please specify)
i.e.
Communications:
Telephone, 2way radios,
generators,
etc.MANPOWE

R (Please
specifyDoctors/Dentis
ts/Nurses/Supp
ort Staff, etc)

SECTION
VIII

ORGANIZATI
ONS
LIST OF
ORGANIZATI
ONS OR
SOCIAL
GROUPS

WHICH
YOU HAVE
BEEN A
MEMBER OF:
ORGANIZATIO
N PLACE DATE
OF MEMBERSH

IP POSITION
HELD

SECTION IX

REQUIRED
CLEARANCES
and

ATTACHMEN
TS
a. NBI CLEARA
NCE a. NBI CLE
ARANCEb.
POLICE
CLEARANCEb.
POLICE

CLEARANCEc. B
ARANGAY CLE
ARANCE c. BAR
ANGAY CLEAR
ANCEd. ORIEN
TATION SEMI
NAR CERTIFIC
ATE (copy) d. O

RIENTATION
SEMINAR CER
TIFICATE (cop
y)
(All of the listed
Items must be
included with the
application
package)

MA

2009 Page 3 of
4 MEMBERSHI
P APPLICATIO
N

SECTION X


MISCELLANE
OUS
COPY THE
FOLLOWING
PARAGRAPH IN
YOUR OWN

HANDWRITIN
G.
As Luis F.
Repazo of 105
th

Xavier Ave.,
guzzled his way
through three

bottles of
brandy,
Josephine Z.
Quinsing,
apartner in the
law firm of San
Diego and
Ballesteros,

located at 2879
Valley Forge
St., Quezon
City, turned to
RichardTing Sr.,
a Chinese food
expert from
O.W. Kwantung

Company Ltd.,
346 Hadji
Jairula Huss
ein Blvd., and
said, I cant
formy
Government but
Im quite sure

your country
and mine better
get together
for closer
understanding.

SECTION XI

APPLICANT
STATEMENT
AND
SIGNATURE
I have ( ) have
not ( ) been
convicted of a

violation of any
laws of
the Republic of
the Philippines,
classified as
a majormisdeme
anor or a felony,
(If convicted of

a major
misdemeanor or
felony, state
specifics,
including date,
city &
stateoffense/s
occurred,

disposition and
comments and
attach to this
application.) I
affirm under
the penalties of
perjury asto
the truth of all

the statements
contained in
this application
and authorize
verification for
the official use
of thePhilippine
Coast Guard or

Philippine
Coast Guard
Auxiliary. I
understand
that any false
statement
contained
herein

isgrounds for
my
disenrollment
from the
Philippine Coast
Guard
Auxiliary.I
PLEDGE TO

SUPPORT THE
PHILIPPINE
COAST GUARD
AUXILIARY
AND ITS
PURPOSES
AND TO ABIDE
BY

THEGOVERNIN
G POLICIES
ESTABLISHED
BY THE
COMMANDANT
OF THE
PHILIPPINE
COAST GUARD.

NAME AND SI
GNATURE OF
SPONSOR DAT
E NAME AND
SIGNATURE O
F APPLICANT
THUMBMARKS

SECTION
XII

SQUADRON
DIRECTOR
ENDORSEME
NT

APPLICANT
IS:( )
ACCEPTED( )
NOT ACCEPTE
DSQUADRON
DIRECTOR SI
GNATURE DAT
E

Note: If applicant
is not accepted,
explain in detail
below

LEFTRIGHT
Please paste here2 x 2
colored photowith
white background

ANNEX III.
APPLICANTS
PERSONAL
HISTORY
STATEMENT
FORM

PERSONAL
HISTORY
STATEMENT
INSTRUCTI
ON
S1. Answer all
the questions co
mpletely; if the
question is not

applicable, write
NA.
WriteUNKNOW
N 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 youdo not
have sufficient
space.2. Type,

print or write
carefully, illegible
or incomplete
forms will not
receive
consideration.W A
R N I N G1.

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 fo
r denialof
clearance.
3. The statement
made herein is cla
ssified
CONFIDENTIAL

. Revelation or
use for
purposes other
than that
authorized is
prohibited
by pertinent
provisions of
AFPRG 200-

052. __________
______________
______________
______________
______________
______
I. PERSONAL D
ETAILS

A. Name:
___________ ___
______________
______________
______________
_ (Last) (First)
(Middle)B. Rank:
____________
PCGSN: _______

_______ Br/Svc:
______________
___ C.
Present Job / Assi
gnment: _______
______________
______________
______________
_ 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):
______________
________ H.

Nicknames:____
______________
___ Nationality:
_____________ I.
TIN: _______
___________ Nat
ional Reg. Card:

_________
__________ J.
Religion:
______________
______ Blood
Type: _________
__________

II. PERSONAL C
HARACTERISTI
CS
A. Description:
Sex: _______
Age: ____
Height: ___ (cms)
Weight _
(kgs)Build (heavy,

Medium, Light):
_____
Complexion
(Dark, Fair,
Light):
_____ Color of
Eyes:
__________
Color of Hair:

____
______ 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 H
ISTORY
A. Marital Status:
______________
______________

______________
_____________ (
Single, Married,
Separated or
Widow)B. Name
of Spouse:
______________
______________
______________

___________ (Ful
l Name)Date
and Place
of Marriage:
______________
______________
______________
__ Occupation
and

Place of Employm
ent: ___________
______________
___________ C.
Children: Name D
ate of
Birth Citizenship

IV. FAMILY HIS

TORY AND INF
ORMATION
A.

Fathers Name: __
______________
______________

______________
_________
(Full name)Date
and Place of
Birth: _________
______________
______________
_________ Addre
ss: ____________

______________
______________
______________
____ Occupation
and Place
of Employment: _
______________
______________
_____ Citizenship

: ____________ if
naturalized, give
date and place
where naturalized
B. Mothers
Name: _ _______
______________
______________
______________

__ (Full
Name)Date
and Place
of Birth: _______
______________
______________
___________ Ad
dress: _________
______________

______________
______________
_______ Occupati
on and Place
of Employment: _
______________
______________
_____ Citizenship
: _____________

if naturalized,
give date and
place where
naturalizedC.
Brothers and
Sisters NAME A
GE ADDRESS O
CCUPATIOND. S
tep-parent

or Guardian:
______________
______________
______________
_______ Address
______________
______________
______________
______________

______ Occupatio
n and Place of
Employment
______________
______________
__________ Citiz
enship
______________
____ if

naturalized, give
date and place
where naturalized

E. Father-in-Law
______________
______________
______________
______________
_ Date and Place
of Birth
______________
______________

______________
________ Addres
s _____________
______________
______________
______________
_______ (Street) (
Bo/Brgy) (Town/
City) __________

______________
_________ Tel Nr
______________
______________
__ (Province)Occ
upation and
Place of
Employment
______________

______________
__________ Citiz
enship_________
_________ If
naturalized, give
date and place
where
naturalizedF. Mot
her-in-Law _____

______________
______________
______________
_________ Date
and Place of Birth
______________
______________
______________
________ Addres

s _____________
______________
______________
______________
_______ (Street) (
Bo/Brgy) (Town/
City) __________
______________
_____ Tel Nr

______________
______________
______ (Province
)Occupation and
Place of
Employment
______________
______________
___________ Citi

zenship
______________
____ if
naturalized, give
date and place
where naturalized
V. EDUCATION
AL BACKGROU
ND

A.
ElementarySchool
Location Date of
AttendanceYear
GraduatedB. High
SchoolSchool Loc
ation Date of Atte
ndanceYear
GraduatedC.

CollegeSchool Co
urse Location Dat
e of AttendanceYe
ar GraduatedD.
Post
GraduateSchool C
ourse Location Da
te of AttendanceY
ear GraduatedE.

Other Schools
Attended and
Date
of AttendanceSch
ool Course Locati
on Date of Attend
anceYear Graduat
edF. 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 Schools
& Location Date
of

Attendance Natur
e of
Training RatingE.
Decorations and
Awards or
Commendations
Received _______
______________
______________

______________
______________
__________ ___
______________
______________
______________
______________
______________
______________

______________
______________
______________
______________
__
VII. PLACES OF
RESIDENCE SIN
CE BIRTHVIII.
EMPLOYMENT

InclusiveDatesTy
pe of Employment
Name/Address of
Employment Reas
on of LeavingHav
e you ever been
dismissed or
forced to resign
from a position?

Yes ________No
______ If yes, exp
lain ___________
______________
_________
IX. FOREIGN C
OUNTRIES VISI
TED (In chronolo
gical order)

Date Country Visi

ted Purpose of Vis
it
X. CREDIT REP
UTATION
A.
Are you entirely
dependent on your

salary? Yes
______ No
______ if no, state
other sources of in
come
______________
______________
______________
____________ 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
agencyYes _____
No _____ If so,
what, agency?
______________
______________
_______ D.

Have you
filed your last
income
tax return?
______________
______________
______ E.

Three (3) credit

references in
the Philippines: N
ame Address
XI.
ARREST
RECORD AND
CONDUCT

A. Have you ever

investigated /
arrested, indicted
or convicted for
any violation of
law? __________
____? If so, state
name of court, nat
ure of offense and

disposition of case
. _____________
______________
______________
______________
_____________ 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
anddisposition
of case.
______________
______________
_____________ C
.

Have you, ever

been charged in
any Administrativ
e Case?
______________
________ D.

Have you ever

been arrested or
detained pursuant
to the provision of
PD 1081 and
itsimplementation
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: Na
me Business
Address/Residenc
e(Include Street &
Number)
B.

List down three

(3) neighbors at
your present
residence: Name
Business
Address/Residenc
e(Include Street &
Number)

XIII.
ORGANIZATIO
N
List of
organization or
social groups
which you have
been a
member:Organizat

ion Address Date

of Membership &
Positionheld
XIV.
MISCELLANEO
US
A.

Hobbies, sports
and
past times ______
______________
______________
______________
______________
__________ ___
______________

______________
______________
______________
_ B.
Language and
Dialect (indicate
ability as fluent,
fair or

poor):Language or
Dialect Speak Rea
d WriteC.
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 105
th

Xavier Ave
guzzled his way
trhough three
bottles of brandy,
Josephine
Z Quinsing, a
partner in law
firm of San Diego
and

Ballesteros locate
d at2879 Valley
Forge St., Quezon
City turned
to Richard Ting
Sr., a Chinese
food expert
fromO.W.
Kwantung

Company, Ltd.,
346 Hadji
Jairul Hussein
Blvd., and said, I
cant speak for
my Government
but Im quite sure
your country and
mine better get

together for
closer understandi
ng.
_____________
______________
______________
______________
____________ _
______________

______________
______________
______________
______________
__ ___________
______________
______________
______________
______________

______ _______
______________
______________
______________
______________
__________ ___
______________
______________
______________

______________
______________
______________
______________
______________
______________
______________
___ __________
______________

______________
______________
______________
_______ ______
______________
______________
______________
_____