REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF JUSTICE


NATIONAL BUREAU OF INVESTIGATION
REFERENCE NUMBER
NBI CLEARANCE APPLICATION FORM
76UXTP37
Tuesday Sep 27, 2016 PM
Valid Until Oct 12, 2016
()
APPLICANT TYPE 1. ID PRESENTED 2. PURPOSE TYPE 3. PURPOSE APPLICATION
- Driver license LOCAL LOCAL EMPLOYMENT

BASIC INFORMATION
5. FAMILY NAME 6. HUSBAND FAMILY NAME (FOR MARRIED WOMAN ONLY)
PAMINTUAN -

7. GIVEN NAME 8. MIDDLE NAME

PAULINO VIRAY

9. NICKNAME 10. OTHER NAME/ALSO KNOW AS

PIPO -

11. DATE OF BIRTH 12. BIRTH PLACE

10/15/1986 CALOOCAN

13. CITIZENSHIP 14. GENDER 15. CIVIL STATUS

FILIPINO MALE MARRIED

16. SPOUSE 17. BIRTH PLACE

CHARIELYN PAMPLONA PAMINTUAN CAVITE

18. PRESENT ADDRESS

PHASE 4A, BLK 11, LOT 9, BRGY MINUYAN

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

09972740521 Boonicha24@gmail.com -
ADDITIONAL INFORMATION

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

163 63 FAIR ROMAN CATHOLIC

26. EDUCATIONAL ATTAINMENT 27. OCCUPATION

VOCATIONAL N/A

PARENTS INFORMATION
28. NAME OF FATHER 29. FATHER BIRTH PLACE
NARCISO MERCADO PAMINTUAN PAMPANGA

30. NAME OF MOTHER 31. MOTHER BIRTH PLACE

ANITA VIRAY PAMINTUAN PAMPANGA

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

© 2015 All Rights Reserved