PERSONAL HISTORY STATEMENT

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 which you
do not have sufficient space.
2. Type, print or write carefully, illegible or incomplete forms will not receive consideration.

WAR N I N G

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 statement made herein is classified "CONFIDENTIAL." Revelation or use for

purpose other than that authorized is prohibited by pertinent provisions of AFPRG 200-052.

I. PERSONAL DETAILS

A. Name: ESGUERRA RANDOLF JASON DELOS REYES

(Last) (First) (Middle)
B. Rank: PCGSN: Br/Svc:

C. Present Job / Assignment: SAFETY OFFICER PASIG DRRMO

D. Business or Duty Address: CARUNCHO AVE. SAN NICHOLAS PASIG CITY

E. Home Address (Include St. & Nr): 3 MARIA ST. SUAREZVILLE SUBDIVISION PINAGBUHATAN PASIG CITY

F. Birth Date: 20-Nov-87 Place of Birth: PASIG CITY

G. Change in Name (If by Court Action give details):

H. Nickname: RJ Nationality: FILIPINO

I. TIN: 262-639-477-000 National Reg. Card: UNKNOWN

J. Religion: CATHOLIC Blood Type: O

II. PERSONAL CHARACTERISTICS

A. Description: Sex: MALE Age: 31 Height: 176 (cms) Weigh: 98 (kgs)

Build (heavy, Medium, Light): MEDIUM Complexion (Dark, Fair, Light): FAIR

Color of Eyes: BLACK Color of Hair: BLACK

Scars or marks and other distinguishing features: BIRTHMARK ON FOREHEAD

B. Physical Condition/Present State of health (Excellent, Good, Poor) EXCELLENT

Physical or Mental Defects: N/A Recent serious Illnes: N/A

III. MARITAL HISTORY

A. Marital Status: SINGLE

(Single, Married, Separated or Widow)
B. Name of Spouse: JOANNE CASHMERE S. MIZUSHIMA
(Full Name)
Date and Place of Marriage: N/A

Occupation and Place of Employment: OFW / TOKYO , JAPAN

C. Children:
Name Date of Birth Citizenship
COCOA M. SUGIYAMA 8-Jun-12 FILIPINO / JAPANESE

IV. FAMILY HISTORY AND INFORMATION

A. Father's Name: GAMMALIEL DELA PAZ OSORIO

(Full name)
Date and Place of Birth: PASIG CITY

Address: SAN JOAQUIN PASIG CITY

Occupation and Place of Employment: GOVERNMENT EMPLOYEE / USA

Citizenship: FILIPINO / AMERICAN If naturalized, give date and place where naturalized

B. Mother's Name: LINDA DELOS REYES ESGUERRA

(Full name)
Date and Place of Birth: REAL QUEZON

Address: 3 MARIA ST SUAREZVILLE SUBDIVISION PINAGBUHATAN PASIG CITY

Occupation and Place of Employment: BUSINESSWOMAN / PASIG CITY

Citizenship: FILIPINO If naturalized, give date and place where naturalized

C. Brothers and Sisters

NAME AGE ADDRESS OCCUPATION
3 MARIA ST SUAREZVILLE
JOSHUA DALE RAMA 21 SUBDIVISION PINAGBUHATAN PASIG
STUDENT
CITY
JOHN PAUL CRISOSTOMO
3 MARIA ST SUAREZVILLE
26 SUBDIVISION PINAGBUHATAN
SYSTEM
PASIG
ANALYST
CITY

D. Step-parent or Guardian: N/A

Address: N/A

Occupation and Place of Employment: N/A

 Citizenship: N/A If naturalized, give date and place where naturalized

E. Father-in-Law: N/A

Date and Place of Birth: N/A

Address: N/A
(Street) (Bo/Brgy) (Town/City)
N/A Tel Nr: N/A
(Province)
Occupation and Place of Employment: N/A
Citizenship: N/A If naturalized, give date and place where naturalized

F. Mother-in-Law: N/A

Date and Place of Birth: N/A

Address: UNKNOWN
(Street) (Bo/Brgy) (Town/City)
ISABELA Tel Nr: UNKNOWN
(Province)
Occupation and Place of Employment: OFW / BOLOGNA, ITALY
Citizenship: FILIPINO If naturalized, give date and place where naturalized

V. EDUCATIONAL BACKGROUND

A. Elementary
School Location Date of Year Graduated
Attendance
St. Stephens Elem. School Masangkay St., Manila

B. High School
School Location Date of Year Graduated
Attendance
PCU-ISS Malate, Manila 1995-1997 1997

C. College
School Course Location Date of Year
Attendance Graduated
PCU BSCS TAFT AVE., MLA. 1997-1998
Marikina Polytechnic College BSCS Marikina 1998-2001 2001

D. Graduate
School Course Location Date of Year
Attendance Graduated
Marikina Polytechnic College BSCS Marikina 1998-2001 2001

E. Other Schools Attended and Date of Attendance

School Course Location Date of Year
Attendance Graduated

F. Civil Service Eligibility, if any, and others similar qualifications N/A

VI. MILITARY HISTORY

A. Date Enlisted in the AFP N/A

B. Date of Commision N/A Source of Commission N/A

C. Important Unit Assignment since Enlistment/CAD: N/A

D. Military Schools Attended

Name of Schools & Location Date of Attendance Name of Training Rating

NINO JESUS HOUSE OF STUDIES 2002-04 CITIZENS ARM TRAINING
CORP COMMANDER
N/A N/A N/A

E. Decorations and Awards or Commendations Received

N/A

VII. PLACES OF RESIDENCE SINCE BIRTH

Inclusive Dates Places/Address

VIII. EMPLOYMENT

Inclusive Type of Employment Name/Address of Employment Reason of

Dates Leaving
2016-PRESENT REGULAR/SALES DIRECTOR ECOSHIFT CORPORATION
2002-2016 REGULAR/SALES MANAGER SSIS SHELVES STORAGE EQPT. PERSONAL REASONS

2015-2016 REGULAR/SALES/MKTG. MNGR. INNOVALITE ELEC. ENT. PERSONAL REASONS

2011-2015 REGULAR/SALES MANAGERCENTER POINT SALES TRADING INC. PERSONAL REASONS

2006-2011 REGULAR/OPERATION FIELD OFFICER BOARDWALK BUSINESS VENTURES INC. PERSONAL REASONS

Have you ever been dismissed or forced to resign from a position? Yes No x
If yes, explain
IX. FOREIGN COUNTRIES VISITED (In Chronological order)

Date Country Visited Purpose of Visit

2015 HONGKONG, CHINA BUSINESS

X. CREDIT REPUTATION

A. Are you entirely dependent on your salary? Yes No X if no, state other
sources of income TNVS OPERATOR/DRIVER
B. Name you Address of Banks or other Credit/Institution with which you have accounts/loans:
N/A
C. Have you filed a statement of your Assets and Liabilities with any government agency
Yes No x If so, what, agency?
D. Have you filed your last income tax return? UNKNOWN
E. Three (3) credit references in the Philippines:
Name Address

XI. ARREST RECORD AND CONDUCT

A. Have you ever investigated / arrested, indicted or convicted for any violation of law? NO
? If so, state name of court, nature of offense and disposition of case.
N/A
B. Has any member of your family ever been investigated / arrested, indicted or convicted for
any violation of law? NO If so, state name of court, nature of the case and
disposition of case. N/A
C. Have you, ever been charged in any Administrative Case? NO
D. Have you ever been arrested or detained pursuant to the provision of PD 1081 and its
implementation order (GO, PO, LOI)? NO If so, state the nature of the case and the
place of your detention N/A
E. Do you use intoxicating liquor or narcotics? NO If so, what extent?
N/A

XII. GENERAL REPUTATION

A. Give five (5) character references (not relatives) known three years or longer, who are not your
relatives:
Name Business Address/Residence
(Include Street & Number)
CAPT. VICTOR EDWIN BLANCAS BF HOMES LAS PINAS / 09228203684
MRS. FLERIDA ARIAS BF HOMES HOMES LAS PINAS / 09175613383
MR. HENRY LACTAM JR. DAS MARINAS CAVITE / 09279689671
MR. REYNALDO BAES JR. LOWER BICUTAN, TAGUIG / 09152499358
 B. List down three (3) neighbors at your present residence:

Name Business Address/Residence

(Include Street & Number)
MR. TROY DAVID 373 STA. NATIVIDAD ST. SAV 6 PQUE CITY
MR. PATRICK PACHICO 364 STA. NATIVIDAD ST. SAV6 PQUE CITY
MR. THOMAS LOPEZ FONDEVILLA 372C STA. NATIVIDAD ST.SAV6 PQUE CITY

XIII. ORGANIZATION

List of organization or social groups which you have been a member:

Organization Address Date of Membership & Position

held

PATAG (AIRSOFT TEAM) PARANAQUE CITY 2007 - PRESENT

MOTORCYCLE PHILIPPINES UNKNOWN 2004-PRESENT (MEMBER)

XVI. MISCELLANEOUS

A. Hobbies, sports and past times

B. Language and Dialect (indicate ability as fluent, fair or poor):

Language or Dialect Speak Read Write

C. Are you willing to undergo periodic lie detection test?

D. 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 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 corect to the best of my knowledge and belief
and I agree that my 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)

THUMBMARKS

2 x 2 picture

LEFT RIGHT

Subscribed and sworn to before me this dat of ###

Philippines, affiant exhibited to me his /her Community Certificate Nr
Issued o at

(Administrative Officer/Notary Public)

(Rank and Designation)

(TIN)