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CCS-A-CDR-2016 Request for Certified True Copy of Derogatory Records
BI request for certified true copy of derogatory records
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CCS-A-CDR-2016
This document may be reproduced and is NOT FOR SALE
REQUEST FOR CERTIFIED TRUE COPY OF
TIFIED
DEROGATORY RECORD
RECORDS
Instructions:
1. Use black ink only and do not leave any space blank. Write N/A if not applicable. Improperly/incompletely filled out application form will not be
o
acted upon.
2. If the application is filed by an authorized representative, attach a photocopy of the Bureau of Immigration (BI) Accreditation Iden
Identification
(ID) Certificate or an original Special Power of Attorney (SPA) for EACH applicant with a photocopy of a valid governmen
government-issued ID of
attorney-in-fact.
SUBJECT’S PERSONAL INFORMATION
’S
Last Name
First/Given Name
Middle Name
Other Name(s)/Alias(es)
1
2
Date of Birth [DD-MMM-YYYY e.g. 01 JAN 1990
1990]
Gender
M
F
Place of Birth
Citizenship/Nationality
Residential/Registered Address in the Philippines
House/Unit No., Street, Subdivision/Village
/Village
Barangay, Municipality/City
Province, Zip Code
Passport Number
Contact Number(s) in the Philippines
Landline
Mobile
Documents to be certified: ______________
_______________________________________________________
_______________________________________________________
Purpose: ______________________________
_________________________________________________________________________________
____________________________________________________
_________________________________________________________________________________________________________
________________________________
Date [DD-MMM-YYYY e.g. 01 JAN 1990]
____________________________________________
________________
Signature over PRINTED NAME of the Requesting Party
Certification and Clearance Section (CCS) Window
ertification
RECEI
RECEIVED: _________________________________
______________
Date & Time
RELEASED: _______
________________________________________
_____________
Date & Time
[To be filled out by Authorized BI Personnel Only]
CERTIFIED TRUE COPY OF DEROGATORY RECORDS CLAIM STUB
Name of SUBJECT [Last Name, First/Given Name, Middle Name]
Last
_______________________
Date of Birth [DD-MMM-YYYY e.g. 01 JAN 1990]
YYYY
Citizenship/Nationality
Always present this claim stub upon claiming your certificate
certificate.
Unclaimed certificate shall be automatically cancelled after 30 days from the date of issuance
issuance.
If claimed by an authorized representative, present a Special Power of Attorney (SPA) and original
valid government-issued ID.
Date & Time FILED
_______________________
Date & Time RELEASED
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