REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF JUSTICE

NATIONAL BUREAU OF INVESTIGATION

NBI CLEARANCE APPLICATION FORM

 REFERENCE NUMBER

MP3NZBETLP
Friday Jan 28, 2022 PM

Valid Until Feb 12, 2022

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APPLICANT TYPE
1. ID PRESENTED
2. PURPOSE TYPE
3. PURPOSE APPLICATION

NEW DRIVERSLIC|M05-20-005858 LOCAL MULTI-PURPOSE CLEARANCE

BASIC INFORMATION

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

7. GIVEN NAME
8. MIDDLE NAME

NABIL DISOMANGCOP

9. NICKNAME
10. OTHER NAME/ALSO KNOW AS

NABIL -

11. DATE OF BIRTH

12. BIRTH PLACE

04/05/1999 LOWER DANSALAN, MARAWI CITY, LANAO DEL SUR

13. CITIZENSHIP
14. GENDER
15. CIVIL STATUS

FILIPINO MALE SINGLE

16. SPOUSE
17. BIRTH PLACE

- -

18. PRESENT ADDRESS

DISOMANGCOP VILLAGE, TOLALI

19. CONTACT NUMBER

20. EMAIL ADDRESS
21. IDENTIFYING MARKS

09311911377 nabil15kmia@gmail.com NONE

ADDITIONAL INFORMATION

22. HEIGHT
23. WEIGHT
24. COMPLEXION
25. RELIGION

156 65 FAIR ISLAM

26. EDUCATIONAL ATTAINMENT

27. OCCUPATION

COLLEGE LEVEL NONE

PARENTS INFORMATION

28. NAME OF FATHER 29. FATHER BIRTH PLACE

TALIB RACMAN DISOMANGCOP MARAWI CITY

30. NAME OF MOTHER

31. MOTHER BIRTH PLACE
NORMINA MUSANIP DISOMANGCOP MARAWI CITY

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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