Nbi Clearance Form – Fill Out and Use This PDF

WRITE LEGIBLY IN BLOCK CAPITAL LETTERS

Republic of the Philippines

CLEARANCE PROCESSING CENTER:

(ISULAT SA PAMAMAGITAN NG MALALAKING TITIK

Department of Justice

BRANCH:__________________

ANG MGA SAGOT)

NATIONAL BUREAU OF INVESTIGATION

FALSIFICATION PUNISHABLE UNDER ART. 171 & 172 OF THE REVISED PENAL CODE

NBI Biometric Clearance System (NBCS)

OR* NUMBER: ________________________________

CLEARANCE APPLICATION FORM

DATE: ______________________________

(FOR CASHIER’S USE ONLY)

ID

CIVIL

PRESENTED:

SEX:

CITIZENSHIP

STATUS:

(Indicate ID Number)

PURPOSE:

SCARS / MARKS / PECULIARITIES:

COMPLEXION

RELIGION

LAST NAME:

HEIGHT

WEIGHT

______ ft OR ______ cm

____ lbs OR ____ Kg

HUSBAND’S SURNAME

NAME OF Husband or Wife

PLACE OF BIRTH(INDICATE TOWN/CITY,

PROVINCE)

FOR MARRIED WOMAN:

FIRST NAME:

NAME OF FATHER

PLACE OF BIRTH(INDICATE TOWN/CITY,

PROVINCE)

MIDDLE NAME:

NAME OF MOTHER (Maiden Name)

PLACE OF BIRTH(INDICATE TOWN/CITY,

PROVINCE)

NICKNAME:

APPLICANT IS ALIEN (PLEASE CHECK IF APPLICABLE AND FILL UP BELOW)

OTHER NAME / AKA:

PASSPORT or ACR

PRESENT ADDRESS:

NAME:

ADDRESS

ABROAD:

DATE OF

PLACE

PASSPORT NUMBER:

DATE

PLACE

BIRTH:

OF BIRTH

____________________________________________________________________________________________________________________________________________________________________

ISSUED

ISSUED

MONTH

DATE

YEAR

(INDICATE TOWN/CITY, PROVINCE)

HIGHEST

OCCUPATION

ACR NUMBER:

DATE

PLACE

EDUCATIONAL ATTAINMENT

ISSUED

ISSUED

NUMBER / S

ADDRESS

THIS FORM IS NOT FOR SALE

CONTACT

e-MAIL

I HEREBY CERTIFY THAT THE FOREGOING

FOR NBI USE ONLY

SUNDRY INFORMATION

STATEMENTS ARE TRUE AND CORRECT

REMARKS

FALSIFICATION PUNISHABLE UNDER ART. 171 & 172 OF THE REVISED PENAL CODE

R/C: ________

Q/C: _________

________________________________________

SIGNATURE OF APPLICANT

FN: Revised NBI Clearance Application Form V1.7