REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF JUSTICE
NATIONAL BUREAU OF INVESTIGATION

NBI CLEARANCE APPLICATION FORM

 REFERENCE NUMBER

FRFEEABPZB
Saturday Feb 18, 2023 AM
Valid Until Mar 05, 2023
()
APPLICANT TYPE 1. ID PRESENTED 2. PURPOSE TYPE 3. PURPOSE APPLICATION
NEW PHILHEALTH| LOCAL MULTI-PURPOSE CLEARANCE

BASIC INFORMATION

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

COMETA -

7. GIVEN NAME 8. MIDDLE NAME

KIMBERY DEA TORRE

9. NICKNAME 10. OTHER NAME/ALSO KNOW AS

KIM -

11. DATE OF BIRTH 12. BIRTH PLACE

08/08/2002 BATANGS

13. CITIZENSHIP 14. GENDER 15. CIVIL STATUS

FILIPINO FEMALE SINGLE

16. SPOUSE 17. BIRTH PLACE

- -

18. PRESENT ADDRESS

BLK40J LOT27 PH3 E2 LONGO MALAON CITY

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

09673671378 cometakimpot@gmail.com NONE

ADDITIONAL INFORMATION

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

5'6 60 FAIR CHRISTIAN

26. EDUCATIONAL ATTAINMENT 27. OCCUPATION

COLLEGE LEVEL -

PARENTS INFORMATION

28. NAME OF FATHER 29. FATHER BIRTH PLACE

EDGARDO DE CASTRO COMETA CANDELARIA

30. NAME OF MOTHER 31. MOTHER BIRTH PLACE

NORA VINAZ DELA TORRE POLANGUI

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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