REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF JUSTICE
NATIONAL BUREAU OF INVESTIGATION

NBI CLEARANCE APPLICATION FORM

 REFERENCE NUMBER

MP3JIJUBPG
Saturday Feb 17, 2024 AM
Valid Until Mar 03, 2024
()
APPLICANT TYPE 1. ID PRESENTED 2. PURPOSE TYPE 3. PURPOSE APPLICATION
NEW VOTERSID|3506-0122A-F0586JAM20000 LOCAL MULTI-PURPOSE CLEARANCE

BASIC INFORMATION

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

ATIS MAHUSAY

7. GIVEN NAME 8. MIDDLE NAME

JEANETH CALAGO

9. NICKNAME 10. OTHER NAME/ALSO KNOW AS

- -

11. DATE OF BIRTH 12. BIRTH PLACE

06/05/1986 BARANGAY PIKALAWAG KAROMATAN LANAO DEL NORTE

13. CITIZENSHIP 14. GENDER 15. CIVIL STATUS

FILIPINO FEMALE MARRIED

16. SPOUSE 17. BIRTH PLACE

GENARD BALUCAN MAHUSAY BARANGAY PIKALAWAG KAROMATAN LANAO DEL NORTE

18. PRESENT ADDRESS

PUROK 3 BARANGAY PIKALAWAG SULTAN NAGA DIMAPORO LANAO DEL NORTE

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

09979807176 firdaushiaibrahim@gmail.com -

ADDITIONAL INFORMATION

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

154 50 FAIR SEVENTH DAY ADVENTIST

26. EDUCATIONAL ATTAINMENT 27. OCCUPATION

HIGH SCHOOL GRADUATE UNEMPLOYED

PARENTS INFORMATION

28. NAME OF FATHER 29. FATHER BIRTH PLACE

FELIXBERTO ABE ATIS BARANGAY PIKALAWAG KAROMATAN LANAO DEL NORTE

30. NAME OF MOTHER 31. MOTHER BIRTH PLACE

BEBIANA JOCSON CALAGO BARANGAY TAGULO KAROMATAN LANAO DEL NORTE

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