Doc. No.     :     ________________

Service No.:     ________________

Series of     :   ________________

O. R. No.   :     ________________

Fee Paid   :    ________________

2”x2” Colored Photograph

royal blue background taken within last six (6) months, without eyeglasses, clearly showing the full front view of the face

DO NOT PASTE OR STAPLE PHOTOS, STORE THEM IN PHOTO POUCH OR FOLDER

FRONT VIEW

2”x2” Colored Photograph

royal blue background taken within last six (6) months, without eyeglasses, clearly showing the full front view of the face

DO NOT PASTE OR STAPLE PHOTOS, STORE THEM IN PHOTO POUCH OR FOLDER

FRONT VIEW

2”x2” Colored Photograph

royal blue background taken within last six (6) months, without eyeglasses, clearly showing the full front view of the face

DO NOT PASTE OR STAPLE PHOTOS, STORE THEM IN PHOTO POUCH OR FOLDER

FRONT VIEW

1.NAME AS WRITTEN ON PHILIPPINE BIRTH CERTIFICATE OR REPORT OF BIRTH

1a. LAST NAME (Surname or family name)

1b. FIRST NAME (Given name)

1c. MIDDLE NAME

2. ARE YOU USING A DIFFERENT NAME?

□ YES           □ NO

IF YES, INDICATE NAME CURRENTLY USED

2a. LAST NAME (Surname or Family name

2b.FIRST NAME (given name)

2c. MIDDLE NAME

3.DOB: BIRTH DATE

MONTH

YEAR

4. PLACE OF BIRTH (town or city, province or state country)

5. SEX

□MALE □FEMALE

6.CIVIL STATUS

7.EYE COLOR

8.HAIR COLOR

9.HEIGHT

10.WEIGHT

11.DISTINGUISHING MARKS

12a. NAME OF SPOUSE (Last name, first name, full middle name)

12b. CITIZENSHIP OF SPOUSE AT THE TIME OF PETITION

13a.NAME OF APPLICANT’S FATHER(Last name, first name, full middle name)

13b. FATHER’S CITIZENSHIP AT THE TIME OF APPLICANT’S BIRTH

14a. NAME OF APPLICANT’S MOTHER (Last name, first name, full middle name)

14b. MOTHER’S CITIZENSHIP AT THE TIME OF APPLICANT’S BIRTH

15a. HOW PHILIPPINE CITIZENSHIP WAS INITIALLY ACQUIRED:

□ BIRTH       □ ELECTION       □ MARRIAGE     □ NATURALIZATION   □ OTHERS (Specify) ______________    

16a. APPLICANT’S CURRENT FOREIGN CITIZENSHIP WAS INITIALLY ACQUIRED

16b MODE OF ACQUISITION OF FOREIGN CITIZENSHIP (specify all)

17a. DATE OF ACQUISITION OF FOREIGN CITIZENSHIP (day/month/year)

17b.NATURALIZATION CERTIFICATE NUMBER

18a. FOREIGN PASSPORT NUMBER/VALID FOREIGN GOV’T. ISSUED ID NUMBER

18b. DATE AND PLACE OF ISSUANCE

19. SUPPORTING DOCUMENTS SUBMITTED: □ Birth Certificate     □ Report of Birth   □ Naturalization Certificate □ Old Philippine Passport                      □ Marriage Certificate □ Others (Specify) __________________

20. PHILIPPINE PERMANNT ADDRESS (house number, street, town or city, province, country postal code)

21. ADDRESS ABROAD OR COUNTRY OF RESIDENCE (house number, street, town or city, country, postal code)

22. HOME TELEPHONE NUMBER

23. E-MAIL ADDRESS / MOBILE PHONE NUMBER

24. PRESENT OCCUPATION

25. WORK ADDRESS (office name, building number, street, town or city, postal code)

26. APPLICANT’S SIGNATURE

DEPENDENT MINOR CHILD NO. 1

Two (2) 2”x2” Colored Photograph

Royal blue background taken within last six (6) months, without eyeglasses, clearly showing the full front view of the face

DO NOT PASTE OR STAPLE PHOTOS, STORE THEM IN PHOTO POUCH OR FOLDER

FRONT VIEW

DEPENDENT MINOR CHILD NO. 2

Two (2) 2”x2” Colored Photograph

Royal blue background taken within last six (6) months, without eyeglasses, clearly showing the full front view of the face

DO NOT PASTE OR STAPLE PHOTOS, STORE THEM IN PHOTO POUCH OR FOLDER

FRONT VIEW

DEPENDENT MINOR CHILD NO. 3

Two (2) 2”x2” Colored Photograph

Royal blue background taken within last six (6) months, without eyeglasses, clearly showing the full front view of the face

DO NOT PASTE OR STAPLE PHOTOS, STORE THEM IN PHOTO POUCH OR FOLDER

FRONT VIEW

INFORMATION OF CHILDREN       -      the following details about each minor child included in the petition shall be provided below

-       (if there are more than three dependent children included in the petition, reprint/photocopy this page)

CHILD 1

CHILD 2

CHILD 3

LAST NAME

(Surname or family name)

FIRST NAME

(Given names)

MIDDLE NAME

(mother’s maiden surname, or applicant’s maiden surname)

SEX

□ MALE      □ FEMALE

□ MALE       □ FEMALE

□ MALE       □ FEMALE

DATE OF BIRTH

AGE

PLACE OF BIRTH

(Town or city, province, state, country)

CITIZENSHIP

COUNTRY OF PERMANENT RESIDENCE

SUPPORTING DOCUMENTS