SECURITY CLEARANCE FORM

Current 2x2 Colored

Picture,

WARNING
1. Answer all questions completely, if question is no applicable, write “NA”. Write unknown if you do not
know the answer and cannot obtain the answer from personal records. Use the bank pages at the back
of this for extra details on any questions for which you do not have sufficient space.
2. Type, print or write carefully and eligibility, incomplete form will not received consideration
3. The statement made herein our classified CONFIDENTIAL.

I. PERSONAL DETAILS:
A. Name:
(Last Name) (First Name) (Middle Name)
B.
C. Business & Address:
D. Home Address:
E. Birth Date: Place:
F.

G. Nick Name: Nationality:

II. PERSONAL CHARACTERISTICS:

A. Description: Sex Age: Height Ft Inches
B. Weight: (Lbs) Build: Heavy: Medium: Slim:
C. Physical condition:
Present state of health: (Excellent, Good, Poor)
Physical or mental defect:
Recent serious illness:

III. MARITAL HISTORY:

A. Marital Status:
(Single) (Married) (Separated) (Widowed)
B. Name of Spouse:
(Include Maiden Name)
Date & Place of Marriage:
Spouse Occupation & Place of Employment:

C. Children:
Name Date of Birth Citizenship & Address

IV. FAMILY HISTORY & INFORMATION:

A. Father: Place of Birth:
Address:
Occupation & Place of Employment:
Citizenship: (If Naturalized give date & place where naturalized)
B. Mother: Place of Birth:
Address:
Occupation & Place of Employment:
Citizenship: (If Naturalized give date & place where naturalized)
C. Brother & Sister:
Name Age Address Occupation
 D. Step Parents or Guardian:
Address:
Occupation & Place of Employment:
Citizenship: (If Naturalized give date & place where naturalized)

V. EDUCATIONAL BACKGROUNDS:
A. Elementary Location Date Attendance Yr Graduate

B. High School Location Date Attendance Yr Graduate

C. College Location Date Attendance Yr Graduate

D. Other School Attended & Date Attendance:

VI. PLACE OF RESIDENCE SINCE BIRTH:

Incl Date Address

VII. EMPLOYMENT:
Incl Date Type of Employment Name & Address of Reason for Leaving
Employment

VIII. ARREST RECORD AND CONDUCT:

A. Have you been investigated / arrested, indicted or convicted for any violation of law? If so, state
name of court, nature of offense and disposition of case.
B. Have any member of your family ever been investigated / arrested indicted or convicted for violation
of law? If so state name of court, nature of offense & disposition of case.
C .Have you ever been charged in any administrative case.
Have you ever been arrested or detained pursuant to the provision of PD 1081 and its implementing
order (GO, PD LOI)? If so, state the nature of the case & the place of your detention.
D. Do you use intoxicating liquor or narcotics? If so, to what extent.

X. GENERAL REPUTATION:
A. Give five (3) character references (Known three (3) years longer who are not your relatives.
Name Address

XII. MISCELLANEOUS:

A. Are you willing to undergo Periodic Lie Detection Test? YES

I certify that the foregoing answer are true correct to the best of my knowledge and belief and
I agree that my misstatement or commission to material facts will constitute ground for immediate
denial of my application for clearance.

Signed at _ on ___________________________

____________________
(Signature of Applicant)