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_____________________________________, ____________________________________
__________________________________
Date of Birth: __________________ Age: _____ Place of Birth: _________________ Nationality: ________________
Sex: [ ] Male [ ]Female
Civil Status: [ ] Single [ ] Married [ ] Widowed [ ] Separated [ ] Divorced
If married, state name and address of spouse:
I solemnly swear that the foregoing statements are true to the best of my knowledge:
Date: _________________
_______________________________________________________
(Signature of Applicant)
_______________________________
Consul General /
Consul
of the Republic of the
Philippines
Non-Immigrant Visa No. ___________________ under Section ______ of the Philippine Immigration Act of 1940,
as amended issued to ______________________________________________________on ____________________ and
valid until _____________________
Remarks, if any:
________________________________________________________________________________________________
Service No.: ________________
OR No.: ___________________
Fee Paid: ___________________
________________________________________
Consul General /
Consul
of the Republic of the
Philippines