VCU Form 1

THIS FORM IS NOT FOR SALE,

REPRODUCTION IS ALLOWED
Jan. 2009

REQUEST FOR BI INTELLIGENCE CLEARANCE (BIC)

[NO Derogatory Record of HDO/BL/WL]

V.C.U. Window
Date: ______________, 200_
RECEIVE:_____________
THE COMMISSIONER ___
THIS BUREAU Date & Time

Dear Sir/Madam : RELEASE:

_______________
May I request a certification for BI Intelligence Clearance :

SURNAME
FIRST NAME
MIDDLE NAME
OTHER NAME
Purpose: ______________________________________________________
OTHER INFORMATION
SEX M F
Month / Day / Year

DATE OF BIRTH / /
PLACE OF BIRTH
NATIONALITY
PHILIPPINE ADDRESS

PASSPORT NO.
TEL. NO./CEL. NO
Very truly yours,
CERTIFICATION FEES :
______________________
SIGNATURE of Requesting Party Certification Fee 500.00
Legal Research
10.00
___________________________ Express Fee
PRINTED NAME of Requesting Party
500.00
TOTAL PhP
1,010.00

Collected under C.A. No. 613,

Section 42(A)(19)

REQUIREMENTS : Attach photocopy of passport of the SUBJECT (data page)

VCU Form 1
Bureau of Immigration
Verification & Certification Unit

________________________
CLAIM STUB Date & Time FILED:

BI Intelligence Clearance Certification

________________________
Date & Time RELEASED:

Name of SUBJECT : _________________________________________________________ ________________________

Proceed to WINDOW:
Date of Birth : __________________ Nationality : __________________________

Always present this receipt upon claiming your certificate

Unclaimed certificate shall be automatically cancelled after 30 days from the date of issuance
If not the claimant of certificate, present authorization letter and valid ID Cards

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