NBI Clearance Application Form

WRITE LEGIBLY IN BLOCK CAPITAL LETTERS

(ISULAT NG MALINAW ANG MGA SAGOT) FALSIFICATION FALSIFICATION PUNISHABLE UNDER ART. 171 & 172 OF THE REVISED PENAL CODE

OR ____ _____________________ _______ * NUMBER: _________________________

CLEARANCE PROCESSING CENTER:

Republic of the Philippines Department of Justice NATIONAL BUREAU OF INVESTIGATION

BRANCH:__________________  DATE: _________________________________

CLEARANCE APPLICATION FORM

(FOR CASHIER’S USE ONLY) ONL Y)

ID PRESENTED:

SEX:

(Indicate ID Number)

CIVIL SATUS:

 APPLICANT IS ALIEN

CITIZENSHIP

(PLEASE CHECK IF APPLICABLE)

PASSPORT or ACR NAME:

PURPOSE:

 ADDRESS  ABROAD:

LAST NAME: HUSBAND’S SURNAME FOR MARRIED WOMAN: GIVEN NAME: MIDDLE NAME:

PASSPORT NUMBER:

DATE ISSUED

PLACE ISSUED

 ACR NUMBER:

DATE ISSUED

PLACE ISSUED

SCARS / MARKS / PECULRIATIES:

NICKNAME:

HEIGHT

WEIGHT   _______ ft

OTHER NAME / AKA: PRESENT ADDRESS:

DATE OF BIRTH:

MONTH

COMPLEXION

DATE DATE

YEAR

PLACE OF BIRTH

HIGHEST CONTACT NUMBER / S

e-MAIL  ADDRESS

FOR NBI USE ONLY REMARKS Q/C:

______ Kg

NAME OF SPOUSE

PLACE OF BIRTH (INDICATE TOWN/CITY, PROVINCE)

NAME OF FATHER

PLACE OF BIRTH (INDICATE TOWN/CITY, PROVINCE)

NAME OF MOTHER

PLACE OF BIRTH (INDICATE TOWN/CITY, PROVINCE)

(INDICATE TOWN/CITY, PROVINCE)

THIS FORM IS NOT FOR SALE SUNDRY INFORMATION

R/C:

  _______ lbs RELIGION

 ______________________________________________ _____________________________________________________ _____________________________________________________ __________________________________________________________ __________________________________________________________ _______ _______

OCCUPATION

EDUCATIONAL EDUCATIONAL ATTAINMENT

_______ cm

I HEREBY CERTIFY THAT THE FOREGOING STATEMENTS ARE TRUE AND CORRECT