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2014-13-009 Rev 0 Request for NICA Clearance
BI request form for NICA Clearance
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This document may be reproduced and is NOT FOR SALE
APPLICATION FORM FOR REQUEST FOR NICA CLEARANCE
Attach your 2x2 colored photograph
with white background
using permanent glue in the
photograph box.
The photograph must be taken
within the last three (3) months
from the date of application.
A scanned photograph is not
allowed. A photograph of the
applicant wearing eyewear (i.e.
sunglasses, colored contact lenses,
etc.) or headwear is not acceptable.
REMINDERS:
1. Accomplish this form in two (2) copies and attach a photocopy of the subject’s passport
bio-page (with English translation if written in other foreign language) and latest departure and
arrival stamps.
2. If the application is filed by an authorized representative, attach a photocopy of the Bureau of
Immigration (BI) Accreditation 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.
PURPOSE OF FILING:
Quota
TRV
Student Visa
Special Study Permit (SSP)
SVEG
CBM
Immigrant Visa
Others: _________________________
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
Height [cm]
Weight [kg]
F
Place of Birth
Citizenship/Nationality
Residential/Registered Address in the Philippines
Residential Address Abroad
Barangay, Municipality/City
City, State
Province, Zip Code
Country, Zip Code
House/Unit No., Street, Subdivision/Village
House/Unit No., Street, Subdivision/Village
Contact Number(s) in the Philippines
Landline
Mobile
Passport Number
Date of Latest Arrival [DD-MMM-YYYY e.g. 01 JAN 1990]
Date of Issuance [DD-MMM-YYYY e.g. 01 JAN 1990]
Present Immigration Status
Expiry Date/Valid Until [DD-MMM-YYYY e.g. 01 JAN 1990]
Length of stay
Days
Place of Issuance
Name of Spouse [Last Name, First/Given Name, Middle Name]
Other Name(s)/Alias(es)
1
2
Name(s) of Child(ren) [Last Name, First/Given Name, Middle Name]
1
2
[To be filled out by Authorized BI Personnel Only]
Purpose of Filing
Name of SUBJECT[Last Name, First/Given Name, Middle Name]
TRV
SVEG
CBM
REQUEST FOR NICA CLEARANCE
Immigrant Visa
Quota
Student Visa
Special Study Permit
Others: _________________________
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 card.
____________________________
Date & Time FILED
Page 1 of 2
____________________________
Date & Time RELEASED
BI FORM 2014-13-009 Rev 0
This document may be reproduced and is NOT FOR SALE
APPLICATION FOR REQUEST FOR NICA CLEARANCE
Occupation
Present Occupation
Previous Occupation
Present Employer
Previous Employer
Present Business Address
Room No., Floor No., Building, Street
Previous Business Address
Room No., Floor No., Building, Street
Barangay, Municipality/City
Barangay, Municipality/City
Province, Zip Code
Province, Zip Code
Within the last five (5) years, have you ever been affiliated with or active in (member of, official of, worker of) any organization
devoted in whole or in part to influencing or furthering in the Philippines the political activities, public relations or public policy of any
government? If yes, name at least two (2) organizations with your corresponding positions held, if applicable.
1. Organization
Position Held
2. Organization
Position Held
Have you ever been convicted for violating any law, decree ordinance or regulations by any court or tribunal?
Yes
No
If yes, give particulars:
_____________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________
Name of nearest relative to be notified in case of emergency:
Last Name, First/Given Name, Middle Name
Residential Address in the Philippines
Contact Number(s) in the Philippines
House/Unit No., Street, Subdivision/Village
Landline
Barangay, Municipality/City
Mobile
Province, Zip Code
AFFIDAVIT FOR PERSON 14 YEARS OF AGE OR OLDER
I have read or have had read to me the above
statements and do hereby swear that these
statements are true and complete to the best of my
knowledge and belief:
_______________________________________
Signature over Printed Name
Left
Thumbmark
Right
Thumbmark
Certification and Clearance Section (CCS) Window
RECEIVED: _________________________________________
Date & Time
RELEASED: _________________________________________
Date & Time
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