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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
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:
E. Home Address (Include St. & Nr): Bonotan, Rizal St. Surigao City
CONFIDENTIAL
CONFIDENTIAL
II. PERSONAL CHARACTERISTICS:
A. Description:
B. Physical Condition:
C. Children:
Citizenship: Filipino If naturalized, give Date and Place where naturalized: N/A
Citizenship: Filipino If naturalized, give Date and Place where naturalized: N/A
CONFIDENTIAL
CONFIDENTIAL
Address: N/A
Citizenship: N/A If naturalized, give date and place where naturalized. N/A
E. Father-In-Law: N/A
Address: N/A
Citizenship: Filipino If naturalized, give date and place where naturalized N/A
V. EDUCATIONAL BACKGROUND:
A. Elementary:
B. High School:
C. College:
CONFIDENTIAL
CONFIDENTIAL
D. Post Graduate:
F. Civil Service Eligibility, If any, and other similar qualification acquired: N/A
CONFIDENTIAL
CONFIDENTIAL
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
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
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
CONFIDENTIAL
CONFIDENTIAL
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
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
XIII. ORGANIZATION:
CONFIDENTIAL
CONFIDENTIAL
XIV. MISCELANEOUS
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)
CONFIDENTIAL
CONFIDENTIAL
2x2 photo
GOA A
LEFT RIGHT
CONFIDENTIAL
CONFIDENTIAL
CONFIDENTIAL