Department of Justice BUREAU OF IMMIGRATION

Magallanes Drive, Intramuros Manila 1002 DIRECTIONS:

1. Mark appropriate boxes with X. Indicate N/A if not applicable. Do not leave any space blank. Print all information legibly. 2. Tourist Visa Extension Form not properly accomplished will be summarily denied. 3. Giving of false information by applicant or his/her duly authorized representative will be basis for the summary denial of application. 4. Only representatives duly accredited by the Bureau will be allowed to represent applicant.

This form may be reproduced and is NOT FOR SALE

TOURIST VISA EXTENSION FORM

( BI FORM RADJR-2012-04 ) CHECKLIST OF REQUIREMENTS:
1. Original Valid Passport; 2. Visa Extension Application Form (Form No. RADJR 2012-04); 3. Bureau of Immigration (BI) Clearance Certi cate (to be issued upon ling of application).

Consolidated General Application Form for

APPLICATION INFORMATION
No. of Months requested No. of Months stayed Reason Pleasure Business Health With Valid Special Study Permit Other (specify) With pending other visa application

BI ACCREDITATION NUMBER

NAME OF ACCREDITED AUTHORIZED REPRESENTATIVE

Name of Applicant Last Name

PERSONAL INFORMATION

Address in the Philippines

No. Street, Subdivision, Brgy. Municipality/ City, Province, Zip Code

First Name / Given Name Address Abroad

Middle Name

No. Street, Subdivision, Village, City, State, Country, Zip Code

Other Name / Alias / AKA

Date of Birth [mm-dd-yyyy]

Gender

LAST TRAVEL INFORMATION

Passport Number

Height (cm)

Weight (kg) Expiry Date [mm-dd-yyyy]

Civil Status Single Married Country of Birth Separated in Fact Widower/ Widow Date of Arrival [mm-dd-yyyy] Flight Number Last day of authorized stay [mm-dd-yyyy] Divorced Place of Issuance

Citizenship / Nationality

Last Name, First Name Middle Initial

CHARACTER REFERENCE

Address of Character Reference

No. Street, Subdivision, Brgy. Municipality/ City, Province, Zip Code

Contact Number of Character Reference

Recommendation / Approval

Acting Chief, Visa Extension Section OPS / Derogatory Check Implementation

Date Approved for the Commissioner

C E R T I F I C AT I O N I HEREBY CERTIFY under oath that all the information in this application form, are true and correct base on my own personal knowledge and on authentic documents in my possession. I furthermore warrant that I have complied with all the requirements of the Bureau of Immigration with respect to this application. I understand that my application can be summarily denied by the Bureau if it nds any statement herein to be false, if any document submitted are found to have been falsi ed, or if I fail to comply with all the requirements with respect to my application without prejudice to whatever action the Bureau of Immigration shall take in accordance with applicable laws of the Republic of the Philippines. Date: _______ Applicant

Signature over Printed Name

Assessor Date

Implementor Date

Chief, IRD Date

Character Reference in the Philippines

Last Name, First Name, M.I.

IV. PETITIONERS INFORMATION

Name of Petitioner

Registered Address of Petitioner

No. Street, Subdivision, Brgy. Municipality/ City, Province, Zip code

Residential Address in the Philippines

No. Street, Subdivision, Brgy. Municipality/ City, Province, Zip Code

Contact Number

VI. ACR I-CARD

ACR Number Contact Number Issue Date [mm-dd-yyyy]

III. APPLICANTS TRAVEL INFORMATION

Passport Number

Valid Until [mm-dd-yyyy]

Certificate of Residence Number Place of Issue

Expiry Date / Valid Until

Date of Last Arrival

[mm-dd-yyyy]

DO NOT FILL-UP THIS PORTION

Application Number Received / Recommended by:

Flight Number

Reviewed by:

Approved by:

C E RT I F IC AT ION
I HEREBY CERTIFY under oath that all the information in this application form consisting of two (2) pages, including the page on which this certi cation is written, are true and correct base on my own peresonal knowledge and on authentic documents in my possession. I furthermore warrant that I have complied with all the requirements of the Bureau of Immigration with respect to this application and that I submitted duly certi ed copies / authenticated documents issued under the o cial seal of the o cer having legal custody of their originals in the Philippines and foreign documents with their o cial English translation, duly authenticated by the consul / embassy o cial in the consular o ce of the Philippines in the foreign country where such documents were issued. I understand that my application can be summarily denied by the Bureau if it nds any statement herein to be false, if any document submitted are found to have been falsi ed, or if I fail to comply with all the requirements with respect to my application / petition without prejudice to whatever action the Bureau of Immigration shall take in accordance with applicable laws of the Republic of the Philippines. Date: _____________

Petitioner Signature over Printed Name Republic of the Philippines) City/ Municipality of_________) S.S.

Applicant Signature over Printed Name

Subscribe and sworn to before me this_____day_____________________,_____affiant exhibiting his / her CTC, ACR, Passport number________________________________ issued at ______________________________ on ________________________ . Doc. No. Book No. Page No. Series of.

Notary Public / Administering Officer

Name of Authorized Representative Accreditation Travel Agency / Law O ce BI Accreditation Number Contact Number

ACR I-CARD WILL ONLY BE RELEASED UPON COMPLIANCE / SUBMISSION OF THE FF: 1. If applicant is a minor, either parent may claim the ACR I-card and present indenti cation. 2. If by a travel agent or law rm, submit photocopy of the BI-Accreditation ID card. 3. If claimed by other person, must present special power of attorney (SPA). 4. Attach photocopy of passport bio page of the ACR I-card holder.

Subject: Contact Address Signature

printed name over signature

Claimant:

printed name over signature

[ Please call 527-7557 to check the status of your application ]