Republic of the Philippines

Office of the Deputy Ombudsman for Mindanao

4th Floor, Herrera Building, Alvares Street, Davao City
(Tel.Nos. 221-3431 to 33; Fax No. 221-39-38)

APPLICATION FOR OMBUDSMAN CLEARANCE

IMPORTANT : 1. Please provide all information requested. Incomplete application will not be
processed or will be returned to the applicant.
2. ATTACH UPDATED, ORIGINAL/AUTHENTICATED SERVICE RECORD
3. File not earlier than three (03) months for civilian employees and six (06)
months for AFP/PNP/BJMP/BFP before retirement/resignation date.
4. No Fee Required.
SIR :
I respectfullty request your good office to isue a clearance in my favor :
(Please indicate your purpose by checking ( / ) the appropriate box )
Retirement/Resignation
Promotion

Effective date : ______________________________

Month / Day / Year
Appointment

Transfer

Schooling/Scholarship

NBI Clearance

Loan/Bidding

PRC License

Service Awards

CESB / CESO

Change of Name

Travel

Employment

Your kind consideration on this matter will be greatly appreciated.

Very truly yours,

FIRST NAME

MIDDLE NAME

LAST NAME

HOME ADDRESS : ______________________________________________________________________

NAME OF OFFICE OR COMPANY : ______________________________________________________
POSITION / ITEM : _____________________________________________________________________
ADDRESS : ___________________________________________________________________________

Signature
Tel./ Cell Phone No._____________
--------------------------------------------------------------------------FOR OMBUDSMAN USE ONLY :
REMARKS : ______________________________________________________________________________
VERIFIED : __________________________________________ DATE : ___________________________

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. HISTORY OF EMPLOYMENT :
8.(A) GOVERNMENT OFFICE
NAME OF OFFICE

POSITION

INCLUSIVE
DATE

CAUSE OF
SEPARATION

1.________________________ ______________________ _____________________ __________________

2. _______________________ ______________________ _____________________ __________________
3. _______________________ ______________________ _____________________ __________________
9.(B) PRIVATE OFFICE
NAME OF OFFICE

POSITION

INCLUSIVE
DATE

CAUSE OF
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

_____________________________________________________

RESULT ____________________________________________