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2014-13-006 Rev 0 Request for Travel Records Application Form
BI request form for travel records
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This document may be reproduced and is NOT FOR SALE
APPLICATION FORM FOR REQUEST FOR TRAVEL RECORDS
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
Passport Number
F
Place of Birth
Citizenship/Nationality
Residential/Registered Address in the Philippines
House/Unit No., Street, Subdivision
Barangay, Municipality/City
Province, Zip Code
Contact Number(s) in the Philippines
Landline
Mobile
Requesting Foundation/Agency/Embassy/Others
Contact Number(s) in the Philippines
Landline
Mobile
If for Court/Legal Purposes:
Name of Court: ________________________________________________________________________________________________________
Branch/Place: ________________________________________________ Contact Number (s): _______________________________________
ARRIVAL DATE
[DD-MMM-YYYY e.g. 01 JAN 1990]
FLIGHT NUMBER
DEPARTURE DATE
[DD-MMM-YYYY e.g. 01 JAN 1990]
FLIGHT NUMBER
[Use the back page if necessary]
SIGNATURE over PRINTED NAME of the Requesting Party
Date [DD-MMM-YYYY e.g. 01 JAN 1990]
Contact Number
DO NOT FILL OUT THIS PORTION
NO RECORD ON FILE [For ICTS &CCS only]
Arrival
Departure
From
To
From
To
:
:
:
:
_________________________________
_________________________________
_________________________________
_________________________________
Verified by: _____________________Date/ Time: __________
NOTE
[For Records Section only]
__________________________________________________
__________________________________________________
__________________________________________________
____
Certification and Clearance Section (CCS) Window
_______________________________
RECEIVED
: ___________________________________________________
Date & Time
RELEASED
: ___________________________________________________
Date & Time
[To be filled out by Authorized BI Personnel Only]
TRAVEL RECORDS CLAIM STUB
Name of SUBJECT [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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