APPLICATION FOR RE-ACQUISITION/RETENTION OF PHILIPPINE

APPLICATION FOR RE-ACQUISITION/RETENTION OF PHILIPPINE CITZENSHIP

(RA 9225)

Philippine Embassy

The Hague, the Netherlands

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

DEPENDENTS INCLUDED IN THIS PETITION:

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

CERTIFICATION

I hereby certify under oath that all the information in this general application form comprising of two pages including the page on this Certification is written are true and correct information about myself as an applicant. I further warrant that I have complied with all requirements of the Bureau of Immigration with respect to my application for the Issuance of Identification Certificate (I.C.) and that I submitted duly certified copies of documents issued under the official seal of the officer having legal custody of their originals in the Philippines, and foreign documents with their official translation into English translation duly authenticated by the counsel/embassy official in the foreign service of the Philippines in the foreign country, in compliance with the requirements of the Bureau of Immigration. I understand that my application will not be processed by the Bureau of Immigration if it finds any statement herein to be false, if any document submitted is found to have been falsified, of if I fail to comply with all the requirements of the Bureau of Immigration with respect to my application/petition without prejudice to whatever action(s) the Bureau of Immigration shall take in accordance with applicable laws of the Philippines.

____________________________ ___________________________________________

DATE OF APPLICATION APPLICANT’S SIGNATURE OVER PRINTED NAME

SUBSCRIBED AND SWORN to before me this ____ day of _____________________, 20___ at The Hague, the Netherlands the affiant exhibited to me his/her passport number ____________________ issued at ____________________________ on ___________________________.

_________________________________________