Revised NBI Clearance Application Form V1.7 (Blue)2

WRITE LEGIBLY IN BLOCK CAPITAL LETTERS (ISULAT SA PAMAMAGITAN NG MALALAKING TITIK ANG MGA SAGOT)

OR * NUMBER: ________________________________

DATE: ______________________________

CLEARANCE APPLICATION FORM

(FOR CASHIER’S USE ONLY)

CIVIL STATUS:

SEX:

(Indicate ID Number)

BRANCH:__________________

NATIONAL BUREAU OF INVESTIGATION NBI Biometric Clearance System (NBCS)

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

ID PRESENTED:

CLEARANCE PROCESSING CENTER:

Republic of the Philippines Department of Justice

CITIZENSHIP SCARS / MARKS / PECULIARITIES: COMPLEXION

PURPOSE: LAST NAME:

HEIGHT

______ ft OR NAME OF Husband or Wife

HUSBAND’S SURNAME FOR MARRIED WOMAN: FIRST NAME: MIDDLE NAME: NICKNAME:

______ cm

WEIGHT

____ lbs OR ____ Kg PLACE OF BIRTH(INDICATE TOWN/CITY, PROVINCE)

NAME OF FATHER

PLACE OF BIRTH(INDICATE TOWN/CITY,

NAME OF MOTHER (Maiden Name)

PLACE OF BIRTH(INDICATE TOWN/CITY,

APPLICANT IS ALIEN

OTHER NAME / AKA: PRESENT ADDRESS:

RELIGION

PROVINCE)

PROVINCE)

(PLEASE CHECK IF APPLICABLE AND FILL UP BELOW)

PASSPORT or ACR NAME: ADDRESS ABROAD:

DATE OF BIRTH:

MONTH

DATE

YEAR

HIGHEST

PLACE OF BIRTH

(INDICATE TOWN/CITY, PROVINCE)

OCCUPATION

EDUCATIONAL ATTAINMENT

CONTACT NUMBER / S

PASSPORT NUMBER:

DATE ISSUED

PLACE ISSUED

ACR NUMBER:

DATE ISSUED

PLACE ISSUED

____________________________________________________________________________________________________________________________________________________________________

e-MAIL ADDRESS

FOR NBI USE ONLY REMARKS

THIS FORM IS NOT FOR SALE SUNDRY INFORMATION

I HEREBY CERTIFY THAT THE FOREGOING STATEMENTS ARE TRUE AND CORRECT

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

R/C: ________

Q/C: _________

FN: Revised NBI Clearance Application Form V1.7

________________________________________ SIGNATURE OF APPLICANT