REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF JUSTICE
NATIONAL BUREAU OF INVESTIGATION

NBI CLEARANCE APPLICATION FORM REFERENCE NUMBER

CPSH4NL8
Saturday Feb 25, 2017 AM
Valid Until Mar 12, 2017
()
APPLICANT TYPE 1. ID PRESENTED 2. PURPOSE TYPE 3. PURPOSE APPLICATION
NEW Brgy. Clearance LOCAL ID PURPOSES

BASIC INFORMATION

5. FAMILY NAME 6. HUSBAND FAMILY NAME (FOR MARRIED WOMAN ONLY)

LUMANLAN REYES

7. GIVEN NAME 8. MIDDLE NAME

EVELYN VICTORIA

9. NICKNAME 10. OTHER NAME/ALSO KNOW AS

- -

11. DATE OF BIRTH 12. BIRTH PLACE

06/12/1963 BAMBAN TARLAC

13. CITIZENSHIP 14. GENDER 15. CIVIL STATUS

FILIPINO FEMALE MARRIED

16. SPOUSE 17. BIRTH PLACE

ARNOLD PASAY CITY

18. PRESENT ADDRESS

#313 APARTMENT G, DELOS REYES ST. BRGY. MAMATITANG MABALACAT PAMPANGA

19. CONTACT NUMBER 20. EMAIL ADDRESS 21. IDENTIFYING MARKS

09157294815 evelynreyes0612@gmail.com -
ADDITIONAL INFORMATION
22. HEIGHT 23. WEIGHT 24. COMPLEXION 25. RELIGION
5 55 FAIR ROMAN CATHOLIC

26. EDUCATIONAL ATTAINMENT 27. OCCUPATION

COLLEGE LEVEL MEAT VENDOR
PARENTS INFORMATION

28. NAME OF FATHER 29. FATHER BIRTH PLACE

PEPITO LUMANLAN TARLAC

30. NAME OF MOTHER 31. MOTHER BIRTH PLACE

ESPERANZA TANGLAO BAMBAN TARLAC

I certify that I have read and understood all the questions set forth in this application and answer I have furnished on this form are true and correct to the best acknowledge and belief. I understand that any false or
misleading statement is FALSIFICATION PUNISHABLE UNDER ARTICLE 171 & 172 OR REVISED PENAL CODE

________________________________ ________________________________

36. DATE 37. SIGNATURE

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