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WRITE LEGIBLY IN BLOCK CAPITAL LETTERS (ISULAT NG MALINAW ANG MGA SAGOT)

FALSIFICATION PUNISHABLE UNDER ART. 171 & 172 OF THE REVISED PENAL CODE

Republic of the Philippines Department of Justice

CLEARANCE PROCESSING CENTER:

NATIONAL BUREAU OF INVESTIGATION

BRANCH:__________________
DATE: _________________________________ APPLICANT IS ALIEN
(PLEASE CHECK IF APPLICABLE)

OR NUMBER: ________________________________ *
(FOR CASHIERS USE ONLY)

CLEARANCE APPLICATION FORM


CIVIL SATUS: CITIZENSHIP PASSPORT or ACR NAME: ADDRESS ABROAD: PASSPORT NUMBER: ACR NUMBER:

(Indicate ID Number)

ID PRESENTED:

SEX:

PURPOSE: LAST NAME: HUSBANDS SURNAME FOR MARRIED WOMAN: GIVEN NAME: MIDDLE NAME: NICKNAME: OTHER NAME / AKA: PRESENT ADDRESS:

DATE ISSUED DATE ISSUED

PLACE ISSUED PLACE ISSUED

SCARS / MARKS / PECULRIATIES: HEIGHT COMPLEXION NAME OF SPOUSE WEIGHT RELIGION PLACE OF BIRTH(INDICATE TOWN/CITY, PROVINCE) PLACE OF BIRTH(INDICATE TOWN/CITY, PROVINCE) PLACE OF BIRTH(INDICATE TOWN/CITY, PROVINCE)

_______ ft

_______ cm

_______ lbs

______ Kg

DATE OF BIRTH:

MONTH

DATE

YEAR

PLACE OF BIRTH

NAME OF FATHER
____________________________________________________________________________________________________________________________________________________________________

(INDICATE TOWN/CITY, PROVINCE)

HIGHEST
EDUCATIONAL ATTAINMENT

OCCUPATION e-MAIL ADDRESS

NAME OF MOTHER

CONTACT NUMBER / S FOR NBI USE ONLY REMARKS R/C: ________

THIS FORM IS NOT FOR SALE


SUNDRY INFORMATION
FN: Revised NBI Clearance Application Form V1.2

I HEREBY CERTIFY THAT THE FOREGOING STATEMENTS ARE TRUE AND CORRECT

Q/C: _________

________________________________________ SIGNATURE OF APPLICANT

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