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 blank spaces at the back of this form for extra details on any questions for which you do not have sufficient space. 2. consideration.
Type, print or write carefully; illegible or incomplete forms will not receive WARNING
1. The correctness of all statements or entries made herein will be investigated. 2. Any deliberate omission or distortion of materials, facts may give sufficient cause for denial of clearance. 3. The statements made herein are classified CONFIDENTIAL. Revelation or use for other than authorized purpose is prohibited under the provisions of AFPR G 200-054. I.
PERSONAL DATA: A.
John Robert (First)
PRESENT JOB/ASSIGNMENT: Duty EP LOC NLC
BUSINESS OR DUTY ADDRESS:
HNLC,LOC, Fort San Felipe, Cavite City
E. HOME ADDRESS (include street & number) Mangas 1 Alfonso Cavite F. BIRTHDATE: 17 May 1995 PLACE: Parañaque City G. CHANGE IN NAME(If by court action, give details)
TAX IDENTIFICATION NR: 351-684-132 MOBILE
DATE OF EXPIRATION:
ANNEX A of AFPR G 200-054 dtd 22 September 2014, cont’n;
PERSONAL CHARACTERISTICS: A. DESCRIPTION: Sex: Male (kgs)
Build (Heavy, Medium, Light): Medium Complexion (Dark, Fair, Light): Fair Color of Hair: black on the nose
Scars or Marks & Other Distinguishing Features: mole
B. PHYSICAL CONDITION Present State of Health (Excellent, Good, Poor): Recent Serious Illness: Blood Type: A+ III.
MARITAL HISTORY: A.
Married (Single, Married, Separated or Widowed)
Nikkie P Pamatian (Full Name)
Date & Place of Marriage:
08 Aug 2022 /Alfonso, Cavite
Date of Birth: 23 Dec 1994 Place of Birth: Silang Cavite Occupation/Employer/Place of Employment: DepEd Contact Number: 09509044990 Citizenship: C.
Filipino If dual, N/A (Other Citizenship)
Name of Father/ Mother
(Use back page for additional information)
CONFIDENTIAL ANNEX A of AFPR G 200-054 dtd 22 September 2014, cont’n;
FAMILY HISTORY AND INFORMATION: A. FATHER:
Fernando C Pamatian (Full Name)
Date & Place of Birth: 05 January 1961 Ibajay Aklan Complete Address:
Occupation/Employer/Place of Employment: Deceased Citizenship: Filipino If dual, write both citizenship, if naturalized, give date and place where naturalized) N/A B. MOTHER:
Marites R Pamatian (Full Name) Date & Place of Birth: 22 Jul 1968 Mangas 1 Alfonso Cavite Complete Address:
Mangas 1 Alfonso Cavite
Occupation/Employer/Place of Employment:
Citizenship: Filipino If dual, write both citizenship. If naturalized, give date and place where naturalized C. BROTHERS & SISTERS: NAME
CITIZENSHIP (IF DUAL, WRITE BOTH)
Catherine R Pamatian
Bryan R Pamatian
Mangas 1, Alfonso Cavite
Mangas 1, Alfonso Cavite N/A N/A
STEP- PARENT OR GUARDIAN:
Date & Place of Birth:
Reservist Army N/A N/A
EMPLOYER/ ADDRESS Mangas 1, Alfonso Cavite Tanza Cavite N/A N/A
Occupation/Employer/Place of Employment: N/A Citizenship: N/A If dual, write both citizenship. If naturalized, give date and place where naturalized N/A E. FATHER-IN-LAW: Date & Place of Birth:
Martiniano P Peji (Full Name) 11 Nov 1965/Alfonso Cavite
Esperanza Ilaya Alfonso Cavite CONFIDENTIAL
CONFIDENTIAL Occupation/Employer/Place of Employment:
ANNEX A of AFPR G 200-054 dtd 22 September 2014, cont’n;
Citizenship: N/A If dual, write both citizenship. If naturalized, give date and place where naturalized: N/A F.
Carmencita R Peji (Full Name) 22 Mar 1965/ Alfonso Cavite Cavite
Date & Place of Birth:
Complete Address: Esperanza Ilaya Alfonso Cavite Occupation & Place of Employment: N/A Citizenship: Filipino If dual, write both citizenship. If naturalized, give date and place where naturalized: N/A V.
EDUCATIONAL BACKGROUND: A.
Mangas Elementary School
Date of Attendance
Mangas 1 Alfonso, Cavite
Year Graduated 1998 ______ ______
Alfonso National High Scool
Location Alfonso, Cavite
Date of Attendance 2006
Year Graduated 2011 ______
D. Post Graduate
Location Mangas 1Alfonso, Cavite
Date of Course Taken Attendance Year Graduated 2011
Date of Course Taken/ Attendance Graduated Year
CONFIDENTIAL N/A N/A N/A
ANNEX A of AFPR G 200-054 dtd 22 September 2014, cont’n;
E. Other Schools/Training Attended and Date of Attendance: N/A N/A N/A F.
Civil Service Eligibility/Date Acquired, if any, and Other Similar Qualifications Acquired:
MILITARY HISTORY: A.
Date Enlisted in the AFP:
29 November 2019
Date of Commission:
C. Source of Commission:
D. Important Unit Assignments since Enlistment/CAD: HNLC, , Fort San Felipe, Cavite City
E. Military Schools Attended:: School/Location
Date of Attendance
Nature of Training
SBC CL-04/ NETDC, San Antonio, Zambales
29 Nov 2019-21May2009
F. Decorations, Awards or Commendations Received::
___________ _________ ______
________ ___ ______ ______________________________________
(ANNEX A of AFPR G 200-054 dtd 22 September 2014, cont’n; PLACES OF RESIDENCE SINCE BIRTH:
Since Birth to Present
Mangas 1, Alfonso Cavite
EMPLOYMENT: Inclusive Date
Type of Employment
Name/Address of Employer
Reason for Leaving
Have you ever been dismissed or forced to resign from a position: No (√ ) If yes, explain N/A N/A N/A VIII.
FOREIGN COUNTRIES VISITED: Date of Visit
Purpose of Visit
CREDIT REPUTATION: A. Are you entirely dependent on you salary? Yes (√ ) state other sources of income.
Name and address of banks or other credit institutions with which you have PNSLAI AND AFPSLAI- SANGLEY POINT Cavite City
C. Have you filed a statement of your Assets and Liabilities with any government Agency? Yes ( √ ) No ( ) If so, what Agency and when? OESPA PHILIPPINE NAVY D.
Have you filed your latest Income Tax Returns? CONFIDENTIAL
CONFIDENTIAL Amount paid for the last Calendar Year:
ANNEX A of AFPR G 200-054 dtd 22 September 2014, cont’n
Three (3) credit references in the Philippines: Name
PO3 Lorna R Ocampo SN1 Ramon D Rosano ASN Aljon P Perez X.
Bancod Indang Cavite Mangas 1 AlfonsoCavite Indang Cavite
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. N/A B. Have any member of your immediate family been investigated/arrested, indicated or convicted for any violation of law? Yes ( ) No ( √ ). If so. State name of court, nature of offense and disposition of case. N/A C. Have you ever been charged of any administrative case? Yes ( ) No (√ ) If so. Explain: N/A
D. Have you ever been arrested or detained pursuant to the provisions of PD 1081and it’s implementing orders (GO, PD, LOI)? Yes ( ) No ( √ ). If so. State the nature of the case and the place of your detention. N/A
E. Do you use intoxicating liquor or illegal drugs? Yes ( ) No ( √ ) if so, to what extent? N/A XI.
GENERAL REPUTATION: A. Give five (5) character references (known three years or longer, who are not your relatives): Name
Mr Ariel M Rosano Mark Dave M Credo Amado C Baclao Marites B Sipagan Danilo C Baclao
Mangas 1, Alfonso Cavite Mangas 1, Alfonso Cavite Mangas 1, Alfonso Cavite Mangas 1, Alfonso Cavite Mangas 1, Alfonso Cavite
B. List down three (3) neighbors at your present residence. Name
Rhovean C Baclao Nely C Baclao Rosemarie V Pamatian
Mangas 1, Alfonso Cavite Mangas 1, Alfonso Cavite Mangas 1, Alfonso Cavite
ANNEX A of AFPR G 200-054 dtd 22 September 2014, cont’n
ORGANIZATIONS: C. List of organizations or social groups which you have been a member of Organization AFPSLAI
Address Sangley PT Cavite City
Date of Membership 2020
Position Held Member
MISCELLANEOUS: D. Hobbies, sports and past times. Volleyball, jogging, cooking
ANNEX A of AFPR G 200-054 dtd 22 September 2014, cont’n;
E. Language and dialects (indicate ability as fluent, fair or poor): Language/Dialect
English Fair Fair Fair Tagalog Fluent Fluent Fluent ___________________________________________________________________ F.
Are you willing to undergo periodic lie detector test?
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 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 22 September 2014, 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 to the material fact will constitute ground for immediate denial of my application for clearance. Signed at HNLC NSPL FSF Cavite City
06 February 2023
(Signature of Applicant) (Witness)
SUBSCRIBED AND SWORN before me this 06 day of Philippines. Affiant exhibited to me his/her Military ID No. PN-EP-06056 Fort Bonifacio Tagiug City on 03 September 2020.
February 2023 issued at
CONFIDENTIAL ANNEX A of AFPR G 200-054 dtd 22 September 2014, cont’n
Sketch of Residence
HNLC, NSPL, FSF, Cavite City
Mangas 1,Alfonso Cavite Pamatian Residence
