Republic of the Philippines

OFFICE OF THE OMBUDSMAN

Agham Road, Diliman, Quezon City

APPLICATION FOR OMBUDSMAN CLEARANCE

THE OMBUDSMAN
ATTENTION: CLEARANCE, PUBLIC ASSISTANCE BUREAU (PAB)
SIR:
I respectfully request your good office to issue a clearance in my favor:

DATE OF RETIREMENT

______________
MONTH

DATE OF RESIGNATION

______________
MONTH

_______________
DATE

______________
YEAR

_______________
DATE

______________
YEAR

NBI CLEARANCE
OTHERS (please specify)

____________________________________________________

_______________________________________________________________________________
Your kind consideration on this matter will be greatly appreciated.
Very truly yours,
_________________________
FIRST NAME

_________________________
MIDDLE NAME

_________________________
LAST NAME

HOME ADDRESS : __________________________________________________________________

POSITION/ ITEM: ___________________________________________________________________
NAME OF OFFICE OR COMPANY: : ___________________________________________________
ADDRESS

: ____________________________________________________________________
______________________________
Signature

INFORMATION SHEET
1) NAME OF APPLICANT

___________________ _________________ _________________

FIRST NAME
MIDDLE NAME
LAST NAME
2) DATE OF BIRTH _____________________
3) PLACE OF BIRTH_____________________
4) PROVINCIAL ADDRESS __________________________________________________________
5) CITY ADDRESS _______________________________________________________________
6.a CIVIL STATUS __________ 6.b SEX ___________ 7) NAME OF SPOUSE _______________
8) EDUCATIONAL BACKGROUND
SCHOOL ATTENDED

DATE OF
ATTENDANCE

8.a ELEMENTARY
___________________ ______________
8.b. HIGHSCHOOL
___________________ ______________
8.c COLLEGE OR UNIVERSITY__________________ ______________

DEGREE EARNED
____________________
____________________
_ ___ _______________

8.d HIGHEST EDUCATIONAL ATTAINMENT ____________________________________________

9. HISTORY OF EMPLOYMENT
9.a GOVERNMENT OFFICE
NAME OF OFFICE
POSITION
1) ____________________ ________________
2) ____________________ ________________
3) ____________________ ________________

INCLUSIVE
CAUSE OF
DATE
SEPARATION
__________________ ____________________
__________________ ____________________
__________________ ____________________

9.b PRIVATE OFFICE

INCLUSIVE
CAUSE OF
NAME OF OFFICE
POSITION
DATE
SEPARATION
1) ____________________ ________________ ___________________ ____________________
2) ____________________ ________________ ___________________ ____________________
3) ____________________ ________________ ___________________ ____________________
10 Have you been criminally or administratively charged before any court or administrative body?
If so state the:

CASE NO._________________________ and RESULT _____________________________

I DECLARE UNDER THE PENALTIES OF PERJURY THAT THE ANSWERS GIVEN ABOVE ARE
TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
_______________________
DATE ACCOMPLISHED

___________________________
SIGNATURE