WRITE LEGIBLY IN BLOCK CAPITAL LETTERS

(ISULAT SA PAMAMAGITAN NG MALALAKING TITIK

ANG MGA SAGOT)

OR
* NUMBER: ________________________________

DATE: ______________________________

CLEARANCE APPLICATION FORM

(FOR CASHIERS 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

HUSBANDS 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