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
(Indicate ID Number)
STATUS:
SCARS / MARKS / PECULIARITIES:
PURPOSE: 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:
NAME OF FATHER PLACE OF BIRTH(INDICATE TOWN/CITY,
FIRST NAME: PROVINCE)

NAME OF MOTHER (Maiden Name) PLACE OF BIRTH(INDICATE TOWN/CITY,

MIDDLE NAME: 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: MONTH DATE YEAR OF BIRTH ____________________________________________________________________________________________________________________________________________________________________

(INDICATE TOWN/CITY, PROVINCE)

ISSUED ISSUED
HIGHEST ACR NUMBER: DATE PLACE
OCCUPATION
EDUCATIONAL ATTAINMENT ISSUED ISSUED
CONTACT
NUMBER / S
e-MAIL
ADDRESS THIS FORM IS NOT FOR SALE 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: _________
FN: Revised NBI Clearance Application Form V1.7 SIGNATURE OF APPLICANT