OMB Form 1 - December 2019

STAMP HERE

Republic of the Philippines

Office of the Ombudsman

APPLICATION FOR OMBUDSMAN CLEARANCE (OMB Form 1)

NUMBER OF ORIGINAL COPIES REQUESTED:

4 NUMBER OF CERTIFIED COPIES REQUESTED: 10
MODE OF PAYMENT: Please check (√) the appropriate box.

Cash Postal Money Order payable to Others, please specify: Exempted

"Payable to Office of the Ombudsman First time jobseeker
Clearance Fees" Indigent

MODE OF RELEASE: Please check (√) the appropriate box.

pick-up at regular mail private courier

OMB office office * to be provided by the Applicant
*prepaid envelope to be provided by the applicant
present/home address

APPLICANT'S INFORMATION: Please PRINT legibly. Write "N/A" if not applicable

Auguis Inocencia Rañin

Last Name First Name Middle Name

If married, mother's
maiden surname
Current Position:
MIDWIFE III (for female applicant) CANOY

Agency/Office Name: Rural Health Office- LGU-Buenavista

Agency/Office Address: Barangay 3, Poblacion Buenavista, Agusan del Norte 8601

Zip Code

Present Address: Purok 2 Rizal Street Barangay 2

House No./Blk. No. Street Name Barangay
Buenavista 8601
Agusan del Norte
City/Municipality Province Zip Code

Date of Birth: June 17, 1955 Contact Nos.: 63 9101015792 / Sex: Female
mm/dd/yyyy Mobile/Landline

I declare that the answers given above are true and correct to the best of my knowledge and belief. I respectfully request your good office to issue a clearance in my favor.

By signing below, I agree to the Ombudsman Privacy Policy and give my consent to the collection and
processing of my personal data in accordance thereto.

Inocencia R. Auguis May 08, 2020

Signature Over Printed Name of Client Date

IN CASE APPLICATION IS FILED BY AUTHORIZED REPRESENTATIVE OR REQUESTER IN BEHALF OF THE DECEASED PERSON

Auguis Gleen Rañin

Last Name First Name Middle Name

Relation to Applicant/Deceased
Son Gleen R. Auguis July 21, 2020
Signature Over Printed Name of Client Date

TO BE ACCOMPLISHED BY THE RECEIVING PERSONNEL

Amount Paid:
OR Number:
Date of Payment:
Signature of Receiving Personnel:

THIS FORM IS NOT FOR SALE. THIS CAN ALSO BE DOWNLOADED THRU THE OMBUDSMAN WEBSITE AT www.ombudsman.gov.ph