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2014-13-002 Rev 0 Request for BI Clearance Certificate
BI request form for clearance certificate
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This document may be reproduced and is NOT FOR SALE
REQUEST FOR BI CLEARANCE CERTIFICATE
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 acted upon.
2. Attach a photocopy of the subject’s passport bio-page or any valid government-issued ID card.
3. If the application is filed by an authorized representative, attach a photocopy of the Bureau of Immigration (BI) Accreditati on
Identification (ID) Certificate or an original Special Power of Attorney (SPA) for EACH applicant with a photocopy of a valid
government-issued ID of attorney-in-fact.
SUBJECT’S PERSONAL INFORMATION
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]
Gender
M
F
Place of Birth
Citizenship/Nationality
Residential/Registered Address in the Philippines
House/Unit No., Street, Subdivision/Village
Barangay, Municipality/City
Province, Zip Code
Passport Number
Contact Number(s) in the Philippines
Landline
Mobile
Purpose: _________________________________________________________________________________________________________
_________________________________________________________________________________________________________
________________________________
Date [DD-MMM-YYYY e.g. 01 JAN 1990]
____________________________________________
Signature over PRINTED NAME of the Requesting Party
Certification and Clearance Section (CCS) Window
RECEIVED: ________________________________________
Date & Time
RELEASED: ________________________________________
Date & Time
[To be filled out by Authorized BI Personnel Only]
BI CLEARANCE CERTIFICATE CLAIM STUB
Name of SUBJECT’S [Last Name, First/Given Name, Middle Name]
_______________________
Date of Birth [DD-MMM-YYYY e.g. 01 JAN 1990]
Citizenship/Nationality
Always present this claim stub upon claiming your certificate.
Unclaimed certificate shall be automatically cancelled after 30 days from the date of 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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