REQUEST FOR CERTIFICATION

(Check the type of certfcaton you are appyng for. Pease provde the nformaton beng asked.)
BI Intelligence Clearance Pending Application
|No Derogatory Record| |Immgrant & Non-Immgrant Vsa|
Certified True Copy OTHERS
|Bureau of Immgratons Certfcates| |Pease specfy|
________________________

Date: ______________, 200_
THE COISSIONER
THIS BUREAU
Dear Sr/Madam :
May I request a certfcaton for:
SURNAME
FIRST NAME
MIDDLE NAME
OTHER NAME
Purpo!e" ______________________________________________________
OTHER INFORATION
SEX M F
DATE OF BIRTH / /
PLACE OF BIRTH
NATIONALITY
PHILIPPINE ADDRESS
PASSPORT NO.
TEL. NO./CEL. NO
#ery truly your!$
______________________
SI%NATURE of Requestng Party
___________________________
PRINTE& NAE of Requestng Party
NOTE : Please see BACK PAGE for LIST OF DOCUMENTARY REQUIREMENTS for sub!ss!o"#
$CU For %
Bureau of I!&ra'!o"
$er!f!(a'!o" ) Cer'!f!(a'!o" U"!'
C ' A I S T U B
BI I"'ell!&e"(e Cleara"(e PENDING A**l!(a'!o" CTC +Cer'!f!e, True Co*-.
Nae of Sub/e(' : 00000000000000000000000000000000000000000000000000000000000
Da'e of B!r'1 : 000000000000000000 Na'!o"al!'- : 00000000000000000000000000
FRONT PAGE
SPECIFIC REQUIREENT! "
Month / Day / Year
Verification of
DEROGATORY +2DO3BL34L.
NAIA 1
Verifier ________________
Date/Time ______________
NAIA 2
Verifier ________________
Date/Time ______________
$CU For %
THIS FORM IS NOT FOR SALE
REPROD!"TION IS ALLO#ED
$an% 2&&'
DATE 3 TIME
RECEI$ED
$CU 5!",o5
((((((((((((((
2 to ( )o*r+ ,roce++in- *,on ,a.ment /e,en/in- on t)e 0o1*me of a,,1ication
A12a.+ ,re+ent t)i+ recei,t *,on c1aimin- .o*r certificate
!nc1aime/ certificate +)a11 3e a*tomatica11. cance11e/ after (& /a.+ from t)e /ate of i++*ance
If not t)e c1aimant of certificate ,re+ent an. 0a1i/ ID "ar/+
&ATE ) TIE FI'E&"
&ATE ) TIE relea!ed "*
BI INTELLIGENCE CLEARANCE :
Attac)e/ 4ERO4 "OP5 of PASSPORT
PENDING APPLICATION :
Attac)e/ 4ero6 co,. of a,,1ication 7+tam, recei0e/8
CERTIFIFIED TRUE COPY :
Procee/ to Room (&1 (
r/
F1oor at Recor/+ Section
CERTIFICATION FEE+S "
"ertification 9&&%&&
Le-a1 Re+earc) 1&%&&
E6,re++ Fee 9&&%&&
T O T A L P1 P %67%7#77
"o11ecte/ *n/er "%A% No% :1(
Section ;27A871<8
#it) MEMORANDUM ORDER NO# 7897:; /ate/ 8< Se*'eber 8778
FOR PEN&IN% APP'ICATION ON',
PENDING APPLICATION= _________________
Si-nat*re = _________________
Printe/ Name= _________________
Office = _________________
Date = _________________
>A"? PAGE
PROCEDURE:
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After accom,1i+)in- t)i+ form t)e a,,1icant +)o*1/ +ec*re an Or/er Pa.ment S1i, @OPSA an/ ,a. t)e amo*nt at t)e
"a+)ier% After ,a.ment ,re+ent t)e Officia1 Recei,t @ORA to-et)er 2it) t)i+ form at t)e Verification B "ertification !nit in
or/er to ,roce++ t)e "ertification%