Manila Traffic and Parking Bureau

3rd Floor, Manila City Hall

Padre Burgos Avenue
Manila City, Metro Manila

AMNESTY APPLICATION FORM

No Contact Apprehension Program
Name of Applicant: Rolando L. Mendoza
Address: 76 Venezuela St. Betterliving Subd. Parañaque City
Contact No: 0920 960 6026 Email Address: rolandomendoza_57@yahoo.com
Plate No: ACD1816
Proof of Vehicle Ownership (put a ✓ where applicable and attach the required documents):

_____ I am the registered owner of the vehicle

a. Copy of Official Receipt/Certificate of Registration
b. Valid Government Issued ID
c.
d. Special Power of Attorney (if applicant is filing this application on behalf of the
registered owner)

______ I am the buyer/transferee/assignee of the vehicle

a. Copy of Official Receipt/Certificate of Registration
b. Valid Government Issued ID
c. Notarized Deed of Sale/Assignment

I intend to avail the General Amnesty for violations of traffic and parking rules under the No Contact
Apprehension Program of the City of Manila pursuant to Ordinance No. 8773. I confirm and agree that I am
liable to pay for the penalties, fines, surcharges, and/or interests arising from any violation in connection
with my abovementioned vehicle, and that the General Amnesty shall apply such violations committed prior
to October 1 2021 only. I acknowledge that the grant of the General Amnesty subject to approval by the
Manila traffic and Parking Bureau, upon payment of the penalty or fine for the following first violation:

To be filled out by the Manila Traffic and Parking Bureau

NOV Number: _____________________________
PIN: ________________________________________
Penalty/Fine: _____________________________
Payment Validated By: ___________________
Reference No.: ____________________________

___________________________________
(Signature over printed name)

SUBSCRIBED AND SWORN TO BEFORE ME this _______ day of ________ in the city of ______________________, affiant
exhibiting to me his/her competent evidence of Identity in the form of his/her
____________________________________.

NOTARY PUBLIC

Doc No.:
Page No.:
Book No.:
Series of 2021