BI FORM 2014-03-006 Rev 0 This document may be reproduced and is NOT FOR SALE

BI ACCREDITATION APPLICATION FORM

FOR LIAISON OFFICERS AND REPRESENTATIVES

Page 1 of 2

APPLICATION CATEGORY

Law Office Consultancy Office/Corporation Consular Office or Government Organization

Travel Agency Missionary

BONDS

Cash Bond O.R. No.

Surety Bond O.R No.

N/A

I. APPLICATION Nature of Application

New Applicant Renewal

II. APPLICANT’S PERSONAL INFORMATION Last Name

First/Given Name

Middle Name

Other Name(s)/Alias(es)

1

2

Date of Birth [DD-MMM-YYYY e.g. 01 JAN 1990] Gender Civil Status

M F Single Married Annulled

Height [cm] Weight [kg] Separated Widowed Divorced

Citizenship/Nationality

Social Security System (SSS) Number PhilHealth Number

Government Service Insurance System (GSIS) Number Tax Identification Number (TIN)

Company/ Agency Employee Number

Residential Address in the Philippines Contact Number(s) in the Philippines

House/Unit No., Street, Subdivision/Village Landline

Barangay, Municipality/City Mobile

Province, Zip Code Email Address

III. EMPLOYMENT

Name of Office

Designation

Office Address Contact Number(s) in the Philippines

Room No., Floor No., Building, Street Landline

Barangay, Municipality/City Mobile

Province, Zip Code Facsimile

Email Address

Attach your 2x2 colored photograph

with white background using

permanent glue in the

photograph box.

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.

REMINDERS:

1. Accomplish this form by writing as legibly & comprehensively as possible.

2. Check the corresponding box of your answer, if applicable.

3. Submit 2 pieces of 2x2 colored photograph. Paste one photograph on the

corresponding space and submit the other one to the concerned frontline officer.

4. Please comply with the requirements to avoid delay in issuing your

accreditation.

5. Any changes in the provided information without informing the Bureau will be

ground for denial or cancellation of the accreditation.

(INFORMATION PROVIDED WILL BE THE BASIS FOR ID PRINTING.)

BI FORM 2014-03-006 Rev 0 This document may be reproduced and is NOT FOR SALE

BI ACCREDITATION APPLICATION FORM

FOR LIAISON OFFICERS AND REPRESENTATIVES

Page 2 of 2

Name of Office: _______________________________________________________________________________________

________________________________________________________________________________

Received By: _________________________________________________________________________________________

Reviewed By: ________________________________________________________________________________________

Approved By: ________________________________________________________________________________________

Remarks By: _________________________________________________________________________________________

Immigration-related Seminars Attended

1. Title of Seminar

Batch No. Date of Seminar [DD-MMM-YYYY e.g. 01 JAN 1990]

2. Title of Seminar

Batch No. Date of Seminar [DD-MMM-YYYY e.g. 01 JAN 1990]

3. Title of Seminar

Batch No. Date of Seminar [DD-MMM-YYYY e.g. 01 JAN 1990]

IV. EMPLOYMENT HISTORY 1. Organization

Inclusive Dates [DD-MMM-YYYY e.g. 01 MAR 2000 – 20 JUL 2013]

-

2. Organization

Inclusive Dates [DD-MMM-YYYY e.g. 01 MAR 2000 – 20 JUL 2013]

-

3. Organization

Inclusive Dates [DD-MMM-YYYY e.g. 01 MAR 2000 – 20 JUL 2013]

-

4. Organization

Inclusive Dates [DD-MMM-YYYY e.g. 01 MAR 2000 – 20 JUL 2013]

-

V. Have you ever been issued a Ban Order/Cancellation Order in violation of BI Accreditation guidelines or regulations?

YES NO

If YES, give details: _________________________________________________________________________________________________________

[Violation] [Date of Order] [Ban/Cancellation Order Number]

Was your Ban Order lifted? Give details: ________________________________________________________________________________________

[Date of Order] [Lifting Ban Order Number]

I declare that this BI Accreditation Application Form has been accomplished by me, and is true, correct and

complete pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines.

I also authorized the agency head/authorized representative to verify/validate the contents stated herein. I

trust that information shall remain confidential.

________________________________ _________________________________

Date [DD-MMM-YYYY e.g. 01 JAN 1990] Applicant’s Signature over Printed Name