BI FORM 2015-08-001 Rev 0 This document may be reproduced and is NOT FOR SALE

EMIGRATION CLEARANCE CERTIFICATE (ECC) APPLICATION FORM

ECC/SRC No.___________________________________
Attach your 2x2 colored photograph
with white background
I. APPLICATION INFORMATION
using permanent glue in the
photograph box.
RE-ENTRY PERMIT
The photograph must be taken
within the last three (3) months
from the date of application. SPECIAL RETURN CERTIFICATE

A scanned photograph is not

allowed. A photograph of the CERTIFICATE OF EXEMPTION
applicant wearing eyewear (i.e.
sunglasses, colored contact lenses,
etc.) or headwear is not acceptable. (A separate form must be submitted for each application.)

The Honorable
BUREAU OF IMMIGRATION
Manila

Sir:
The undersigned alien hereby makes this sworn application for Re-entry Permit/Special Return Certificate/ Certificate of Exemption/Clearance
Certificate here from, provided for under Section 22 and Section 22-A of the Philippine Immigration Act of 1940, as amended, or Administrative Order
dated 04 June 1954, and the rules and regulations issued and submits the following information in support thereof.
II. APPLICANT’S PERSONAL INFORMATION
Last Name
NGUYEN KINH NHAN
First/Given Name

Middle Name
N / A
Residential Address in the Philippines
House/Unit No., Street, Subdivision
3006 Cityland Shaw Tower
Barangay, Municipality/City
Mandaluyong City
Province, Zip Code
M e t r o M a n i l a
Date of Birth [DD-MMM-YYYY e.g. 01 JAN 1990] Gender Citizenship/Nationality
2 8 A P R 1 9 8 9 x M F V I E T N A M E S E
Marital Status Country of Birth
x Single Annulled Widowed V I E T N A M
Married Separated Divorced
If married, widowed, or divorced, give the name and address of present or former spouse:
Name of Spouse [Last Name, First/Given Name, Middle Name]

Address of Spouse

III. APPLICANT’S TRAVEL INFORMATION

Applicant’s Status of Latest Admission in the Philippines Date of Latest Admission in the Philippines [DD-MMM-YYYY e.g. 01 JAN 1990]

PEZA VISA
Visa downgrade/order to leave
Reason for Leaving: ________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Date of Intended Departure [DD-MMM-YYYY e.g. 01 JAN 1990] Destination

Name of Transportation to Be Taken

Returning in the Philippines? Probably/estimated Length of Stay Abroad [e.g. 20 days, 2 months, etc.]
Yes No
Passport Travel Affidavit No.

Immigration Papers Surrendered to the Bureau of Immigration

Alien Certificate of Registration (ACR) No.

Place of Issuance Date of Issuance [DD-MMM-YYYY e.g. 01 JAN 1990]

Immigration Certificate of Registration (ICR) No.

Place of Issuance Date of Issuance [DD-MMM-YYYY e.g. 01 JAN 1990]

I hereby swear/affirm that all information provided is true and correct to the best of my knowledge and belief; that I voluntarily submitted
authenticated/ original documents to verify my application, and that there exists no pending criminal civil or administrative action which requires my
presence.
NGUYEN KINH NHAN
__________________________________ ___________________________________________________
Date Applicant’s Signature over Printed Name

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