Republic of the Philippines

Department of Justice NATIONAL BUREAU OF INVESTIGATION NBI Biometric Clearance System (NBCS)

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ID PRESENTED: (Indicate ID Number)

SEX: CIVIL STATUS: CITIZENSHIP

PURPOSE:

SCARS / MARKS / PECULIARITIES:

COMPLEXION RELIGION

LAST NAME:

HEIGHT ______ ft OR ______ cm

WEIGHT ____ lbs OR ____ Kg

HUSBAND’S SURNAME FOR MARRIED WOMAN: NAME OF Husband or Wife PLACE OF BIRTH(INDICATE TOWN/CITY,

PROVINCE)

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

NAME:

PRESENT ADDRESS:

ADDRESS ABROAD:

DATE OF BIRTH:

PLACE OF BIRTH

____________________________________________________________________________________________________________________________________________________________________

(INDICATE TOWN/CITY, PROVINCE) PASSPORT NUMBER: DATE ISSUED PLACE

ISSUED

MONTH DATE YEAR HIGHEST

EDUCATIONAL ATTAINMENT OCCUPATION ACR NUMBER: DATE ISSUED PLACE

ISSUED

CONTACT NUMBER / S e-MAIL

ADDRESS THIS FORM IS NOT FOR SALE

WRITE LEGIBLY IN BLOCK CAPITAL LETTERS (ISULAT SA PAMAMAGITAN NG MALALAKING TITIK

ANG MGA SAGOT) FALSIFICATION PUNISHABLE UNDER ART. 171 & 172 OF THE REVISED PENAL CODE

SUNDRY INFORMATION

FOR NBI USE ONLY REMARKS

R/C: ________ Q/C: _________

CLEARANCE PROCESSING CENTER: BRANCH:__________________

CLEARANCE APPLICATION FORM OR NUMBER: ________________________________ (FOR CASHIER’S USE ONLY)

DATE: ______________________________

________________________________________

SIGNATURE OF APPLICANT FN: Revised NBI Clearance Application Form V1.7

I HEREBY CERTIFY THAT THE FOREGOING STATEMENTS ARE TRUE AND CORRECT

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