Philippine Coast Guard Auxiliary Application Form Page 3
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4MA – 2009 Page 3 of 4
MEMBERSHIP APPLICATION
SECTION X – MISCELLANEOUS
COPY THE FOLLOWING PARAGRAPH IN YOUR OWN HANDWRITING.
th
“As Luis F. Repazo of 105
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 for
my Government but I’m quite sure your country and mine better get together for closer understanding.”
SECTION XI – APPLICANT STATEMENT AND SIGNATURE
I have ( ) have not ( ) been convicted of a violation of any laws of the Republic of the Philippines, classified as a major
misdemeanor or a felony, (If convicted of a major misdemeanor or felony, state specifics, including date, city & state
offense/s occurred, disposition and comments and attach to this application.) I affirm under the penalties of perjury as
to the truth of all the statements contained in this application and authorize verification for the official use of the
Philippine Coast Guard or Philippine Coast Guard Auxiliary. I understand that any false statement contained herein is
grounds for my disenrollment from the Philippine Coast Guard Auxiliary.
I PLEDGE TO SUPPORT THE PHILIPPINE COAST GUARD AUXILIARY AND ITS PURPOSES AND TO ABIDE BY THE
GOVERNING POLICIES ESTABLISHED BY THE COMMANDANT OF THE PHILIPPINE COAST GUARD.
NAME AND SIGNATURE OF SPONSOR
DATE
NAME AND SIGNATURE OF APPLICANT
COMMO EDGARDO MIJARES PCGA
05/2002
GERONIMO P REYES
THUMBMARKS
RIGHT
LEFT
Please paste here
2 x 2 colored photo
with white background
SECTION XII – SQUADRON DIRECTOR ENDORSEMENT
APPLICANT IS:
SQUADRON DIRECTOR SIGNATURE
DATE
( ) ACCEPTED
( ) NOT ACCEPTED
Note: If applicant is not accepted, explain in detail below
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