WRITE LEGIBLY IN BLOCK CAPITAL LETTERS

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

(ISULAT SA PAMAMAGITAN NG MALALAKING TITIK ANG MGA SAGOT)

Republic of the Philippines Department of Justice

CLEARANCE PROCESSING CENTER:

OR NUMBER: ________________________________ *
ID PRESENTED:
(FOR CASHIERS USE ONLY)

NATIONAL BUREAU OF INVESTIGATION NBI Biometric Clearance System (NBCS)

BRANCH:__________________
DATE: ______________________________

CLEARANCE APPLICATION FORM

CIVIL STATUS: CITIZENSHIP SCARS / MARKS / PECULIARITIES: COMPLEXION ______ ft OR NAME OF Husband or Wife NAME OF FATHER NAME OF MOTHER (Maiden Name) HEIGHT

(Indicate ID Number)

SEX:

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

RELIGION WEIGHT ____ lbs OR ____ Kg PLACE OF BIRTH(INDICATE TOWN/CITY,

PROVINCE)

______ cm

PLACE OF BIRTH(INDICATE TOWN/CITY,

PROVINCE)

PLACE OF BIRTH(INDICATE TOWN/CITY,

PROVINCE)

APPLICANT IS ALIEN
PASSPORT or ACR NAME: ADDRESS ABROAD:

(PLEASE CHECK IF APPLICABLE AND FILL UP BELOW)

DATE OF BIRTH:

MONTH

DATE

YEAR

PLACE OF BIRTH

PASSPORT NUMBER:
____________________________________________________________________________________________________________________________________________________________________

(INDICATE TOWN/CITY, PROVINCE)

DATE ISSUED DATE ISSUED

PLACE ISSUED PLACE ISSUED

EDUCATIONAL ATTAINMENT

HIGHEST

OCCUPATION e-MAIL ADDRESS

ACR NUMBER:

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

THIS FORM IS NOT FOR SALE

SUNDRY INFORMATION
FN: Revised NBI Clearance Application Form V1.7

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

I HEREBY CERTIFY THAT THE FOREGOING STATEMENTS ARE TRUE AND CORRECT

Q/C: _________

________________________________________ SIGNATURE OF APPLICANT