INFORMATION SHEET

1. Name of Applicant
First Name Middle Name Surname
2. Date & Place of Birth
3. Provincial Address
4. City Address
5. Civil Status If married, name of spouse
6. Highest Educational Attainment
7. Education:
School Attended Date of Attendance
a) Elementary
b) Secondary
c) College or University Course Taken Date of Attendance

8. Are you employed in the government? Yes No
9. Name of Office
Position
Period of Employment: From To
10. If employed in a private office, state name of employer
and your position
Period of employment: From To
11. If previously retired, state date of retirement and name of Office
(Retirement Date) (Name of Office)
12. Have you been criminally or administratively charged before any court or administrative body?
Yes No if yes, state results thereof
13. Are you willing to be placed under a lie detector test?
Yes No
Date Accomplished:
Signature of Applicant
Republic of the Philippines
OFFICE OF THE OMBUDSMAN
Ground Floor, Old Nawasa Bldg.
176 Arroceros Street, Manila
APPLICATION FOR OMBUDSMAN CLEARANCE
THE OMBUDSMAN (Visayas)
Palace of Justice
Cebu City
S i r :
I respectfully request your good Office to issue a clearance in my favor for:
a. Issuance or renewal of passport
b. Issuance of NBI Clearance
c. CID travel clearance
d. Retirement
e. Terminal Leave/Resignation
f. Others (pls. specify)
Your kind consideration on this matter will be greatly appreciated.
Very truly yours,
Signature
FOR VERIFIERS' USE ONLY:
FINDINGS:
LAST NAME FIRST NAME M.I.
ADDRESS
PREVIOUS OR PRESENT OCCUPATION
NAME OF OFFICE OR COMPANY
OFFICE ADDRESS