BI FORM 2015-08-001 Rev 0

This document may be reproduced and is NOT FOR SALE

EMIGRATION CLEARANCE CERTIFICATE (ECC) APPLICATION FORM

ECC/SRC No.___________________________________
Attach your 2x2 colored photograph
with white background
using permanent glue in the
photograph box.

I.

APPLICATION INFORMATION

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.

RE-ENTRY PERMIT
SPECIAL RETURN CERTIFICATE
CERTIFICATE OF EXEMPTION

(A separate form must be submitted for each application.)

The Honorable
BUREAU OF IMMIGRATION
Manila
Sir:
The undersigned alien hereby makes this sworn application for Re-entry Permit/Special Return Certificate/ Certificate of Exemption/Clearance
Certificate here from, provided for under Section 22 and Section 22-A of the Philippine Immigration Act of 1940, as amended, or Administrative Order
dated 04 June 1954, and the rules and regulations issued and submits the following information in support thereof.
II. APPLICANTS PERSONAL INFORMATION
Last Name
First/Given Name
Middle Name
Residential Address in the Philippines
House/Unit No., Street, Subdivision
Barangay, Municipality/City
Province, Zip Code
Date of Birth [DD-MMM-YYYY e.g. 01 JAN 1990]

Gender
M

Marital Status

Citizenship/Nationality
F
Country of Birth

Single

Annulled

Widowed

Married

Separated

Divorced

If married, widowed, or divorced, give the name and address of present or former spouse:
Name of Spouse [Last Name, First/Given Name, Middle Name]
Address of Spouse

III. APPLICANTS TRAVEL INFORMATION

Applicants Status of Latest Admission in the Philippines

Date of Latest Admission in the Philippines

[DD-MMM-YYYY e.g. 01 JAN 1990]

Reason for Leaving: ________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________
Date of Intended Departure [DD-MMM-YYYY e.g. 01 JAN 1990]
Destination
Name of Transportation to Be Taken
Returning in the Philippines?

Yes

Probably/estimated Length of Stay Abroad [e.g. 20 days, 2 months, etc.]

No

Passport Travel Affidavit No.

Immigration Papers Surrendered to the Bureau of Immigration
Alien Certificate of Registration (ACR) No.
Place of Issuance

Date of Issuance [DD-MMM-YYYY e.g. 01 JAN 1990]

Immigration Certificate of Registration (ICR) No.

Place of Issuance

Date of Issuance [DD-MMM-YYYY e.g. 01 JAN 1990]

I hereby swear/affirm that all information provided is true and correct to the best of my knowledge and belief; that I voluntarily submitted
authenticated/ original documents to verify my application, and that there exists no pending criminal civil or administrative action which requires my
presence.
__________________________________
Date

___________________________________________________
Applicants Signature over Printed Name
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