PHS Form ( DFA)

CONFIDENTIAL
PERSONAL HISTORY STATEMENT
INSTRUCTIONS:
1. Answer all questions completely, if question is not applicable write “NA” and
“UNKNOWN” if you do not know the answer and cannot be obtained the answer from
personal records.
2. Type, print or write carefully in black ribbon or ink, illegible or incomplete forms will have
to be done over. Use additional sheets for extra details of any question for which you do
not have sufficient space.
3. Please accomplish this form in duplicate.
This statement made herein are confidential. Revelation or use other than official purpose is prohibited.
I. PERSONAL DATA
(Surname) (First Name) (Middle Name)
_________________________________________________________________________
Nickname/s: _______________________________ Alias/es: ________________________
Rank: _______________________________ Division/Office: ________________________
Designation: _________________________ Tel No. (Local) __________ Rm No. ________
Sex: Male Female Height: ______cm Weight: _______lbs
Date and Place of Birth: _____________________________________________________

Color of Eyes: ____________ Color of Hair: ___________ Complexion: ________________
Built: _____________________ Distinguishing Features: ___________________________
Religion: ______________ Citizenship: __________________ How Acquired: __________
Present Address: ______________________________________ Tel No.: _____________
If married, Name of Spouse: _________________________________________________

Date and Place of Birth: _____________________________________________________
Occupation and Place of Employment: _________________________________________
Parents: Name of Father: ___________________________________________________

Date and Place of Birth: ______________________________________________
Name of Mother: ___________________________________________________
Date and Place of Birth: ______________________________________________
Parents Address: ___________________________________________________
Page I 1
CONFIDENTIAL
Children or Dependents and their Ages:

____________________________________ ___________________________________
____________________________________ ___________________________________
____________________________________ ___________________________________
____________________________________ ___________________________________
____________________________________ ___________________________________
____________________________________ ___________________________________
In-Laws, their Occupation and Addresses:

____________________________________ ___________________________________
____________________________________ ___________________________________
____________________________________ ___________________________________
____________________________________ ___________________________________
II. EDUCATIONAL BACKGROUND
School Attended Address of School Date of Attendance

_________________________ ______________________ _____________________
_________________________ ______________________ _____________________
_________________________ ______________________ _____________________
_________________________ ______________________ _____________________
Course Taken: _________________________________ Year Graduated: _________________________
___________________________ Year Graduated: __________________________
III. EMPLOYMENT HISTORY
From To Position Held Employer Address
______________ ________________ _________________ __________________

______________ ________________ _________________ __________________
______________ ________________ _________________ __________________
______________ ________________ _________________ __________________
______________ ________________ _________________ __________________
Page I 2
CONFIDENTIAL
In-Service Training/Seminars Attended:
Title Conducted by: Duration

_________________________ ________________________ __________________
_________________________ ________________________ __________________
_________________________ ________________________ __________________
_________________________ ________________________ __________________
Civil Service/Board/Bar Examination Taken:

Date Place of Exam Rating
__________________________ __________ _________________ ___________
__________________________ __________ _________________ ___________
__________________________ __________ _________________ ___________
Conference/Meeting Attended:
Title Place Date
__________________________ ___________________________ ____________
__________________________ ___________________________ ____________
__________________________ ___________________________ ____________
Statement of Duties and Responsibilities: (Present Position)

___________________________________ _______________________________
___________________________________ _______________________________
___________________________________ _______________________________
___________________________________ _______________________________
IV. GENERAL QUALIFICATION
Languages and Dialects Spoken/Written and Degree of Proficiency:
Excellent Good Fair Excellent Good Fair
Page I 3
CONFIDENTIAL
Hobbies : ___________________________ Sports: ____________________________

___________________________________ __________________________________
___________________________________ __________________________________
Skills: __________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Publication and Inventions: ________________________________________________

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
V. CHARACTER AND CREDIT REFERENCES

Give two (2) each of Credit, Character and Neighbor:
Name Occupation Address
_______________________ ________________________ ____________________
_______________________ ________________________ ____________________
_______________________ ________________________ ____________________
_______________________ ________________________ ____________________
VI. PLACE OF RESIDENCE SINCE BIRTH
Inclusive Dates Complete Address
______________________________ ______________________________________
______________________________ ______________________________________
______________________________ ______________________________________
______________________________ ______________________________________
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CONFIDENTIAL
VII. TRAVEL ABROAD
Inclusive Date Place Purpose
____________________ ___________________________ ____________________

____________________ ___________________________ ____________________
____________________ ___________________________ ____________________
____________________ ___________________________ ____________________
I HEREBY CERTIFY THAT THE FOREGOING ANSWERS ARE TRUE AND CORRECT TO THE BEST OF
MY KNOWLEDGE, BELIEF AND ABILITY.
____________________________________
Signature of Person Accomplishing this Form
Sign at: ______________________________
On: ____________ TIN No: ______________
SUBCRIBED AND SWORN TO before me this _______ day of ________20__ at ____________
_____________________________________
Administering Officer
Recent Photo Thumb Mark Specimen Signature:
Left Right ______________________________
______________________________
2” x 2” picture
______________________________
Page I 5

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CONFIDENTIAL

PERSONAL HISTORY STATEMENT

Date and Place of Birth: _____________________________________________________

If married, Name of Spouse: _________________________________________________

Parents: Name of Father: ___________________________________________________

Children or Dependents and their Ages:

In-Laws, their Occupation and Addresses:

II. EDUCATIONAL BACKGROUND

School Attended Address of School Date of Attendance

III. EMPLOYMENT HISTORY

From To Position Held Employer Address

______________ ________________ _________________ __________________

In-Service Training/Seminars Attended:

Title Conducted by: Duration

Civil Service/Board/Bar Examination Taken:

Statement of Duties and Responsibilities: (Present Position)

IV. GENERAL QUALIFICATION

Languages and Dialects Spoken/Written and Degree of Proficiency:

Excellent Good Fair Excellent Good Fair

Hobbies : ___________________________ Sports: ____________________________

Publication and Inventions: ________________________________________________

V. CHARACTER AND CREDIT REFERENCES

VI. PLACE OF RESIDENCE SINCE BIRTH

Inclusive Dates Complete Address

VII. TRAVEL ABROAD

Inclusive Date Place Purpose

____________________ ___________________________ ____________________

SUBCRIBED AND SWORN TO before me this _______ day of ________20__ at ____________

Recent Photo Thumb Mark Specimen Signature:

Left Right ______________________________

You might also like

______ _ __________

Hobbies : _ Sports: __

______ _ ________

SUBCRIBED AND SWORN TO before me this _ day of 20 at ________