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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: Agudo Carl Vincent Tantio


(Last) (First) (Middle)
B. Rank: SN2 PCG SN: 011326 Br/ Svc PCG

C. Present Job/ Assignment: CGDNM/ CGS Dinagat Islands

D. Business or Duty Address: Poblacion 1, San Jose Dinagat Islands_______________________

E. Home Address (Include St. & Nr): Bonotan, Rizal St. Surigao City

F. Birth Date: 20 January 1992 Place of Birth: Surigao City

G. Change In Name(If by Court Action give Details: None

H. Nicknames: Vincent Nationality: Filipino

I. TIN: 339-532-029 National Reg. Card: None

J. Religion: Roman Catholic Blood Type: O+

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II. PERSONAL CHARACTERISTICS:

A. Description:

Sex: Male Age: 27 Height: 176 (cms) Weight: 75 (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: None

B. Physical Condition:

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

Physical or Mental Defects: None Recent Serious Illness: None

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


N/A N/A N/A

IV. FAMILY HISTORY AND INFORMATION:

A. Father’s Name: Renato Carumbana Agudo


(Full Name)
Date and Place of Birth: 29 October,1963/ Surigao City

Address: Bonotan, Rizal St. Surigao City


Occupation and Place of Employment: Technician

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

B. Mother’s Name: Monett Tantio Agudo


(Full Name)
Date and Place of Birth: 21 April,1971/ Surigao City

Address: Bonotan, Rizal St. Surigao City


Occupation and Place of Employment: House Wife

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

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C. Brothers and Sisters:

Name Age Address Occupation


Mark Renette T Agudo 29 Bonotan Rizal St.Surigao City Service Man
Via May T Agudo 23 Bonotan Rizal St.Surigao City N/A
Angelica T Agudo 8 Bonotan Rizal St.Surigao City N/A

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: Filipino If naturalized, give date and place where naturalized N/A

V. EDUCATIONAL BACKGROUND:

A. Elementary:

School Location Date of Year Graduated


Attendance
CVDiez Memorial Elementary Surigao City 1998 2004
School

B. High School:

School Location Date of Year Graduated


Attendance
Surigao Del Norte National High Surigao City 2004 2008
School

C. College:

School Location Date of Year Graduated


Attendance
Surigao State College Of Surigao City 2008 2011
Technology

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D. Post Graduate:

School Location Date of Year Graduated


Attendance
N/A N/A N/A N/A

E. Schools Attended and Date of Attendance:

School Location Date of Year Graduated


Attendance
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: 27 July, 2017

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

C. Important Unit Assignments Since Enlistment/CAD: CGDNM

D. Coast Guard School Attended:

NAME OF DATE OF ATTENDANCE NATURE OF TRAINING


SCHOOL/LOCATION

NOBETC 27 July 2017 CGMC Cl 62

E. Decorations, Awards or Commendation Received

Award of the Coast Guard Merit Medal and Ribbon

Award of the Coast Guard Commendation Medal and Ribbon

Award of the Coast Guard Merit Medal and Ribbon

Award of the Coast Guard Merit Medal and Ribbon

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VII. PLACE OF RESIDENCE SINCE BIRTH:

Inclusive Dates Places/Address

1992 up to present Bonotan Rizal St. Surigao City

VIII. EMPLOYMENT:
Inclusive Dates Type of Name/Address of Reason for
Employmen Employment Leaving
t
N/A N/A N/A N/A
Have you everbeen dismissed or forced to resign from a position? Yes No 

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

B. Names and Address of Banks or Other Credit/Institutions with which your have
accounts/loans: PCGSLAI- Muelle Dela Industria Farola Compound, Binondo, Manila

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? NO

Amount paid for the last Calendar Year:

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

Name Address
PCGSLAI Muelle Dela Industria Farola Compound, Binondo,
Manila
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

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B. Has any member of your family ever been investigated/ arrested, indicated or convicted

for any violation of law? N/A If so, state name of court, nature of offense and disposition

of case. N/A

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?

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)
Miguel Paas Alegria,Surigao Del Norte
Erner Paso Alegria,Surigao Del Norte
Jeffrey Villamor Rizal,Surigao City
Jonel Bonotan Rizal,Surigao City
Mark Tudtud Kaskag, Surigao City

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

Name Business Address/Residence


(Include Street/Number)
Neljun Posesano Bonotan Rizal St. Surigao City
Richard Bautista Bonotan Rizal St. Surigao City
Ian James tarife Bonotan Rizal St. Surigao City

XIII. ORGANIZATION:

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

Organization Address Date of Membership &


Position
N/A N/A N/A

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XIV. MISCELANEOUS

A. Hobbies, sports and past times


Watching Movies, Playing Basketball and Online Games

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

Language or Dialect Speak Read Write


Bisaya Fluent Fluent Fluent
Tagalog Fluent Fluent Fluent
English Fair Fluent Fair

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

D. 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 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.”

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 ____________________Date:

____________________________________
(Signature of Applicant)

_______________________________ _________________________________
(Witness) (Witness)

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2x2 photo
GOA A

LEFT RIGHT

Subscribed and sworn to before me this day of 20 Philippines,


affiant exhibited to me his/her Community Certificate Nr.
Issued on _____________________at

ENS RONNIE REY D PABICO PCG


(Administrative Officer/ Notary Public)

STATION COMMANDER/CGS Dinagat Islands


(Rank and Designation)

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E. Scketch of your present residence.

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