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TRANSACTION/S
ACR I-Card Renewal
ACR I-Card Renewal
DEROGATORY RECORD
NO DERO
ACR Replacement
W/ DERO
Checked by : _____________________________
Date
Rejected Card
Damaged Card
: ____________________________
RECOMMENDING
APPROVAL
DENIAL
Remarks: _______________________________
________________________________________
New Address:
Registration Officer
___________________________________________________________________________
Date
REVIEWED BY:
___________________________________________________________________________
___________________________________________________________________________
________________________________________
Remarks:
APPROVED BY:
Reviewing Officer
Date
___________________________________________________________________________
___________________________________________________________________________
________________________________________
___________________________________________________________________________
ARE YOU PLANNING TO LEAVE THE COUNTRY WITHIN THIRTY (30) DAYS UPON
ACR Number
COMM/ARD CHIEF
Date
YES
NO
Visa Status
Last Name
First/Given Name
Age
Gender
Middle Name
Height [cm]
Weight [Kg]
Male
Female
Civil Status
Passport Number
Citizenship/Nationality
Landline Number
Mobile Number
Single
Married
Annulled
Separated
Widowed
Separated
Email Address
Residential Address in the Philippines
House/Unit No., Street, Subdivision/Village, Barangay
Municipality/City, Province, Zip Code
I hereby swear/affirm that the information provided herein are true and correct to the best of my knowledge and belief. I
voluntarily submitted authenticated/original documents/card to further verify my application and that any misrepresentation, omission or
falsification of facts may justify denial and cancellation of my application. Further, I have no pending application not given due course in
other immigration office.
ACR Number
Visa Type
[IF THE ACR I-CARD IS CLAIMED BY AN AUTHORIZED REPRESENTATIVE, PLEASE SEE REVERSE SIDE FOR INSTRUCTIONS.]
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Claimant:_____________________
Signature
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