CONFIDENTIAL

ANNEX A of AFPR G 200-054 dtd 22 September 2014;

GHQ, OJ2 File Nr : ____________

200-054 Form

PERSONAL HISTORYSTATEMENT

INSTRUCTIONS

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 the
blank pages at the back of this form for extra details on any question for which 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 other than the
authorized purpose is prohibited by AFPR G 200-054.

I. PERSONAL DETAILS

A. NAME: ______MAHADALLI___________BERKIS_________ KARIM____________________

(Last) (First) (Middle/Maternal)

B. RANK____P2LT_______AFPSN:___OT-2273________________BR/SVC:___PAF_______

C. PRESENT JOB/ASSIGNMENT: __OFFICER TRAINEE______________________________

D. BUSINESS OR DUTY ADDRESS: ____N/A____________________________________________

E. HOME ADDRESS (Include street & number): __BARANGAY DIKI ISABELA CITY BASILAN_____

_______________________________________________________

F. BIRTHDATE:_ NOVEMBER 14,1993_____ PLACE:__ISABELA CITY_____________

G. CHANGE IN NAME (If by Court Action, give details): _N/A_______________________________

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ANNEX A of AFPR G 200-054 dtd 22 September 2014, cont’n;

H. NICKNAME:__ADIH OR BERKS_________ NATIONALITY:___FILIPINO_________________

I. TAX IDENTIFICATION NR: __________________ TEL NO. _____________________

J. MOBILE PHONE NR: _09656393140_ E-MAIL ADDRESS: berkismahadalli111493@gmail.com_

K. PASSPORT NR: _P3355086B__ DATE OF EXPIRATION: ___25 SEP 2029____

II. PERSONAL CHARACTERISTICS:

A. DESCRIPTION: Sex: FEMALE Age: 27 Height: 157 (M) Weight: 51 (kgs)

Build (Heavy, Medium, Light): _MEDIUM__________________________________

Complexion (Dark, Fair, Light): _FAIR_______Color of Eyes: ___BLACK___________

Color of Hair:_BLACK__ Scars or Marks & Other Distinguishing Features: MOLE IN THE
LEFT FACE_

______________________________________

B. PHYSICAL CONDITION:

Present State of Health (Excellent, good, Poor): _____EXCELLENT____________________

Recent Serious Illness: ___N/A____________________________________________________

III. MARITAL HISTORY

A. MARITAL STATUS: ________SINGLE_____________________________________

(Single, Married, Separated or Widowed)

B. NAME OF SPOUSE: _________N/A________________________________________________

(Full Name)

Date & Place of Marriage: ________N/A_____________________________________________

Date of Birth: _____N/A____________Place of Birth:__N/A_____________________________

Occupation & Place of Employment: ____N/A_________________________________________

___________________________________________________________________________

Contact Number: ____N/A_____ Citizenship:______N/A_______ If Dual, ___________________

(Other Citizenship)

C. CHILDREN:

Name Date of Birth Citizenship/Address

N/A

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ANNEX A of AFPR G 200-054 dtd 22 September 2014, cont’n;

N/A

(Use back page for additional information)

IV. FAMILY HISTORY AND INFORMATION:

A. FATHER: _______ABRAHAM MARAKAG MAHADALLI________________________________

(Full Name)

Date & Place of Birth ____JOLO SULO______________________________________

Complete Address: __ISABELA CITY BASILAN______________________________________

Occupation/Employer/Place of Employment: ___BUSINESSMAN__________________

_________________________________________________________________________

Citizenship: ____FILIPINO___ If dual, write both citizenship. If naturalized, give date

and place where naturalized _____________________________________________.

B. MOTHER: ____AISA KARIM MAHADALLI________________________________________

(Full Name)

Date & Place of Birth ___ISABELA CITY_________________________________________

Complete Address: _____ISABELA CITY___________________________________________

Occupation/Employer/Place of Employment: ____N/A__________________________________

Citizenship: _______FILIPINO_____ If dual, write both citizenship. If naturalized, give date

and place where naturalized ____________________________________________.

C. BROTHERS AND SISTERS:

NAME DATE OF CITIZENSHIP (IF COMPLETE OCCUPATION EMPLOYER/ADDRESS

BIRTH DUAL, WRITE ADDRESS
BOTH)

HASAN KARIM APRIL FILIPINO JOLO SULO SECURITY JOLO SULO

MAHADALLI 15,1986 GUARD

KAUSAR KARIM AUGUST FILIPINO ISABELA OFW DUBAI

MAHADALLI 21,1989 CITY

TALIB KARIM OCTOBE FILIPINO ISABELA STUDENT ISABELA CITY

MAHADALLI R 18,1996 CITY

AL SHARIF KARIM FEBRUA FILIPINO MALAYSIA STUDENT MALAYSIA

MAHADALLI RY
12,2000

NORSIMA SEPTEM FILIPINO MALAYSIA STUDENT MALAYSIA

BER,5,20

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D. STEP-PARENT OR GUARDIAN: SELSA ABUBAKAR AMSANI

(Full Name)
ANNEX A of AFPR G 200-054 dtd 22 September 2014, cont’n;

Date & Place of Birth __ISABELA CITY BASILAN_/NOVEMBER 4,1978___________________

Complete Address: ISABELA CITY________________________________________________

Occupation/Employer/Place of Employment: ___N/A___________________________________

Citizenship: ___FILIPINO_____________________ If dual, write both citizenship. If naturalized,

give date

and place where naturalized ____________________________________________.

E. FATHER-IN-LAW: N/A

(Full Name)

Date & Place of Birth ____N/A_____________________________________________________

Complete Address: _____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 ____________________________________________.

F. MOTHER-IN-LAW: JUHAY KARIM (DECEASED)

(Full Name)

Date & Place of Birth _________________________________________________________

Complete Address: __________________________________________________________

Occupation/Employer/Place of Employment: ______________________________________

Citizenship: ________________________ If dual, write both citizenship. If naturalized, give date

and place where naturalized ____________________________________________.

V. EDUCATIONAL BACKGROUND

A. Elementary Location Date of Year

Attendance Graduated

SOUTHERN SUPPORT COMMAND UPPER CALARIAN JUNE 1999 MARCH 2005

ELEMENTARY SCHOOL ZAMBOANGA CITY

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B. High School Location Date of Year

Attendance Graduated

ZAMBOANG CITY HIGH SCHOOL DON ALFARO STREET JUNE 2005 MARCH 2009

MAIN TETUAN ZAMBOANGA CITY

ANNEX A of AFPR G 200-054 dtd 22 September 2014, cont’n;

Course
Taken/

C. College Location Date of Year

Attendance Graduated

BASILAN STATE COLLEGE BARANGAY SUMAGDANG ISABELA JUNE 2013 MARCH 2017

Course Taken/

D. Post Graduate Location Date of Year

Attendance Graduated

N/A N/A

D. Other Schools/Training Attended and Date of Attendance:

SUMMER CADRE TRAINING APRIL-MAY 2014

F. Civil Service Eligibility, If any and Other Similar Qualifications Acquired:

CRIMINOLOGY LICENSURE EXAM

VI. MILITARY HISTORY:

A. Date Enlisted in the AFP: N/A

B. Date of Commission: N/A

C. Source of Commission: N/A

D. Important Unit Assignments since Enlistment/CAD:

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INCLUSIVE DATES UNIT.OFFICE CHIEF OF OFFICE

N/A

E. Military Schools Attended:

School/Location Date of Nature of

Attendance Training Rating

SUMMER CADRE TRAINING APRIL-MAY 2014

F. Decorations, Awards or Commendations Received:

CRIMINOLOGIST LEADERSHIP AWARD,CHARACTER AWARD,BEST IN TOUNGE TWISTER

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ANNEX A of AFPR G 200-054 dtd 22 September 2014, cont’n;

VII. PLACES OF RESIDENCE SINCE BIRTH:

Inclusive Dates Address

1993-2005 ISABELA CITY BASILAN

2005-2010 ZAMBOANGA CITY
2010-PRESENT ISABELA CITY

VIII. EMPLOYMENT:

Inclusive Dates Type of Name & Address of Employer Reason for Leaving
Employment

OCTOBER- DECEMBER CONTACT TRACER DILG/ISABELA CITY END OF CONTRACT

Have you ever been dismissed or forced to resign from a position: No ( √ ) Yes ( ) If yes, explain

IX. FOREIGN COUNTRIES VISITED:

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Date of Visit Country Visited Purpose of Visit Address Abroad

N/A N/A N/A

ANNEX A of AFPR G 200-054 dtd 22 September 2014, cont’n;

X. CREDIT REPUTATION:

A. Are you entirely dependent on your salary? Yes ( ) No (√ ) if no, state other sources of
income:

B. Name and address of banks or other credit institutions with which you have accounts/loans:
LANDBANK AND BDO

C. Have you filed a statement of your Assets and Liabilities with any government Agency?

Yes ( ) No ( √ ) If so, what Agency and When? _____________________________________

_______________________________________________________________________

D. Have you filed your latest Income Tax Returns? NO

Amount paid for the last Calendar Year: N/A

E. Three (3) credit references in the Philippines:

Name Address

LANDBANK ISABELA CITY

METROBANK ISABELA CITY
BANK OF THE PHILIPPINE ISABELA CITY

XI. 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.

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B. Has any member of your family 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.

C. Have you ever been charged of any administrative case? Yes ( ) No ( √ ) If so, explain:

ANNEX A of AFPR G 200-054 dtd 22 September 2014, cont’n;

D. Have you ever been arrested or detained pursuant to the provisions of PD 1081 and its
implementing orders (GO, PD, LOI)? Yes ( ) No ( √ ) If so, state the nature of the case and the place of
your detention.

E. Do you use intoxicating liquor or narcotics? Yes ( ) No ( √ ) If so, to what extent?

XII. GENERAL REPUTATION:

A. Give five (5) character references (known three years or longer, who are not your relatives):

Name Address

NORMA ASADIL MALAMAWI ,ISABELA CITY

MA.DELIGHT C. BOLLS PORT AREA ISABELA CITY

HAPIBIN J. CAMAL SUMAGDANG ISABELA CITY

THRINITY LAIN G. FULLENTE ISABELA CITY

USSI ISIK MALAMAWI ISABELA CITY

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

Name Address

NORMA ASADIL MALAMAWI, ISABELA CITY

USSI ISIK MALAMAWI ISABELA CITY

HAN MALAMAWI ISABELA CITY

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XIII. ORGANIZATIONS:

C. List of organizations or social groups which you have been a member of

Organization Address Date of Membership Position Held

N/A N/A N/A N/A

ANNEX A of AFPR G 200-054 dtd 22 September 2014, cont’n;

N/A N/A N/A N/A

XIV. MISCELLANEOUS:

D. Hobbies, sports and past times.

PLAYING VOLLEYBALL,PLAYING BADMINTON,PLAYING ONLINE GAMES ,READING BOOKS

READING MAGAZINES

E. Language and dialects (indicate ability as fluent, fair or poor):

Language/Dialect Speak Read Write

TAGALOG FAIR FAIR FAIR

TAUSOG FLUENT FLUENT FLUENT

ENGLISH POOR FAIR POOR

CHAVACANO POOR POOR POOR

F. Are you willing to undergo periodic lie detector test? YES

G. Copy exactly the following paragraph in your own handwriting:

As Luis E Rapazo III of 105th 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
HadjiJairula 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.”

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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 as to a material fact will constitute ground for immediate denial of my
application for clearance.

Signed at Date:

(Witness) (Signature of Applicant)

(Witness)

THUMB MARKS:
2x2 Photo

(Left) (Right)

SUBSCRIBED AND SWORN to before me this ____ of _______at ___________________

Philippines, Affiant exhibited to me his/her Community Tax Certificate Nr. ___________________________

issued at _______________________________ on ___________________________.

(Administering Officer)

Impression taken by:

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Verified by:

ANNEX A of AFPR G 200-054 dtd 22 September 2014, cont’n;

SKETCH OF THE LOCATION OF RESIDENCE

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