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Request for Note Verbale

DFA request form for Issuance of Note Verbale for Holders of Diplomatic and Official Passport

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: DFA-OCA-DOPS-07
REV.00 / DEC 2016

Republic of the Philippines
DEPARTMENT OF FOREIGN AFFAIRS

Diplomatic and Official Passports Section
Tel. No. 834 4000 loc 2292; Fax No. 836 7765; Email: oca.dops@dfa.gov.ph

R e q u e s t f or N o t e Ve r b al e
THIS APPLICATION FORM IS NOT FOR SALE. PLEASE DO NOT LEAVE ANY SPACES BLANK, INDICATE N/A IF NOT APPLICABLE. PROVIDING FALSE
STATEMENTS IN THE PASSPORT APPLICATION IS PUNISHABLE BY LAW (R.A. 8239)

Type of Passport:
Diplomatic
Official

Passport No. :___________________________
Date of Issue :___________________________

____________________

______________________

________________________

LAST NAME

FIRST NAME

MIDDLE NAME

Complete Address
Tel. No. Office
E-mail address

:_____________________________________________________________________
:____________________Home:________________Mobile:______________________
:_____________________________________________________________________

PURPOSE OF TRAVEL

:__________________________________________________________________

DATE OF TRAVEL

:__________________________________________________________________

DESTINATION

:_________________________ Transit via: _______________________________
(As the applicant, securing a visa to your country of transit and/or destination is your responsibility.)

OFFICE OF EMPLOYMENT

:____________________________________________________________________

DESIGNATION

:____________________________________________________________________
(As Stated in the Service Record)

I SOLEMNLY SWEAR UNDER PENALTY OF LAW that the statements made on this application form are true and the
attached documents are authentic.

________________________________________
Signature of Applicant

OR

__________________________________________
Authorized Representative
(Signature over Printed Name)

FOR USE OF THE DEPARTMENT OF FOREIGN AFFAIRS ONLY.
Date

:____________Time:__________

Date of Revalidation

:___________________________

Date of Validity

:___________________________

Processor

:___________________________

Approving Officer

Required Documents :
1. Photocopy of Revalidated Passport
2. Signed Travel Authority
3. Photocopy of Confirmed Flight Itinerary (for In-Transit)

:

RECEIVED NOTE VERBALE:

___________________________________________
Signature Over Printed Name/Date

_____________________________________
FRANK R. CIMAFRANCA
Assistant Secretary
Office of Consular Affairs
 
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