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OMB Application Form

This document contains an application for an Ombudsman clearance submitted by an individual. It includes a request for clearance and provides the applicant's personal details such as name, address, employment history, and educational background. The applicant declares that the information provided is true and correct. The application is submitted to the Office of the Ombudsman for their consideration.

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Dennis Valdez
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© Attribution Non-Commercial (BY-NC)
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64 views2 pages

OMB Application Form

This document contains an application for an Ombudsman clearance submitted by an individual. It includes a request for clearance and provides the applicant's personal details such as name, address, employment history, and educational background. The applicant declares that the information provided is true and correct. The application is submitted to the Office of the Ombudsman for their consideration.

Uploaded by

Dennis Valdez
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Republic of the Philippines

OFFICE OF THE OMBUDSMAN


Agham Road, Diliman, Quezon City

APPLICATION FOR OMBUDSMAN CLEARANCE


THE OMBUDSMAN
ATTENTION: CLEARANCE, PUBLIC ASSISTANCE BUREAU (PAB)
SIR:
I respectfully request your good office to issue a clearance in my favor:

DATE OF RETIREMENT

______________
MONTH

DATE OF RESIGNATION

______________
MONTH

_______________
DATE

______________
YEAR

_______________
DATE

______________
YEAR

NBI CLEARANCE
OTHERS (please specify)

____________________________________________________

_______________________________________________________________________________
Your kind consideration on this matter will be greatly appreciated.
Very truly yours,
_________________________
FIRST NAME

_________________________
MIDDLE NAME

_________________________
LAST NAME

HOME ADDRESS : __________________________________________________________________


POSITION/ ITEM: ___________________________________________________________________
NAME OF OFFICE OR COMPANY: : ___________________________________________________
ADDRESS

: ____________________________________________________________________
______________________________
Signature

INFORMATION SHEET
1) NAME OF APPLICANT

___________________ _________________ _________________


FIRST NAME
MIDDLE NAME
LAST NAME
2) DATE OF BIRTH _____________________
3) PLACE OF BIRTH_____________________
4) PROVINCIAL ADDRESS __________________________________________________________
5) CITY ADDRESS _______________________________________________________________
6.a CIVIL STATUS __________ 6.b SEX ___________ 7) NAME OF SPOUSE _______________
8) EDUCATIONAL BACKGROUND
SCHOOL ATTENDED

DATE OF
ATTENDANCE

8.a ELEMENTARY
___________________ ______________
8.b. HIGHSCHOOL
___________________ ______________
8.c COLLEGE OR UNIVERSITY__________________ ______________

DEGREE EARNED
____________________
____________________
_ ___ _______________

8.d HIGHEST EDUCATIONAL ATTAINMENT ____________________________________________


9. HISTORY OF EMPLOYMENT
9.a GOVERNMENT OFFICE
NAME OF OFFICE
POSITION
1) ____________________ ________________
2) ____________________ ________________
3) ____________________ ________________

INCLUSIVE
CAUSE OF
DATE
SEPARATION
__________________ ____________________
__________________ ____________________
__________________ ____________________

9.b PRIVATE OFFICE


INCLUSIVE
CAUSE OF
NAME OF OFFICE
POSITION
DATE
SEPARATION
1) ____________________ ________________ ___________________ ____________________
2) ____________________ ________________ ___________________ ____________________
3) ____________________ ________________ ___________________ ____________________
10 Have you been criminally or administratively charged before any court or administrative body?
If so state the:

CASE NO._________________________ and RESULT _____________________________


I DECLARE UNDER THE PENALTIES OF PERJURY THAT THE ANSWERS GIVEN ABOVE ARE
TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
_______________________
DATE ACCOMPLISHED

___________________________
SIGNATURE

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