Ombudsman's Clearance Form 4l3s5g
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OMB Form 1-Application for Ombudsman Clearance
Page 1 of 2
Republic of the Philippines Office of the Ombudsman Agham Road, Diliman, Quezon City REQUIREMENTS:
1. Duly accomplished Application for Ombudsman Clearance (OMB Form 1) and any valid ID 2. Photocopy of service record and death certificate for death claims purposes 3. Payment of clearance fee
APPLICATION FOR OMBUDSMAN CLEARANCE CONFORME: By g below, I am agreeing to the Ombudsman and giving my consent to the collection and processing of my personal data in accordance thereto. _____________________________________________ Signature of Client Over Printed Name
PURPOSE OF CLEARANCE : Please indicate the number of copies in the appropriate box. Clearance Fee P100.00
Clearance Fee P200.00
CDD
Expiration of Term
Reversion
Awards, please specify:
Death Claim
GSIS Claims
Separation (Date)
Bar Exam
Guarantorship
Scientific Career System
Disability Retirement
Rationalization
CES Eligibility
Leave Application
Study Grant
Discharge
Resignation (Date)
CESO Rank
Loan Application
SUC Presidency
Dropped from the Roll
Retirement (Date)
Change of Name (Specify Name):
End of Contract (Date)
Commissionship
Nomination
UN Mission
End of Term (Date)
TPPD
Completion of Residency
Recognition
Visa
Expiration of Appointment
Training
Requirement by JBC, CSC, CESB, Office of the
Clearance Fee P150.00
Court Requirement
President, PRC, GOCC, DFA, DOLE, BI, LTO, NBI,
Appointment
Grant of Benefits
Reappointment
Extension of Service
PNP & other agencies: (Please specify agency)
Confirmation
Lateral Entry
Reemployment
Foreign Travel
Employment
Promotion
Transfer
Free and Accepted Masonry
Foreign Assignment
Schooling
ProcessingClearance Fee P1,000.00 Fee P1,000.00
Clearance Fee P500.00 Bidding Requirements
Scholarship
Fidelity Bond
Permit to Carry Firearms
Firearm License
MODE OF PAYMENT: Please one. Cash
SM, Hypermart, Savemore
Landbank
Postal money order payable to "Office of the Ombudsman Clearance Fees"
MODE OF RELEASE : Please one. pick-up at OMB office personally authorized representative
prepaid private courier*
regular mail
*applicant shall provide prepaid envelope except if paid thru SM
office address present/home address
APPLICANT'S INFORMATION: (Please PRINT legibly. Write "N/A" if not applicable) 1. Name of Applicant: First Name
Middle Name
Last Name
Suffix i.e, Jr.
3. If married, mother's maiden surname (for female applicant)
2. Current Position: 4. Agency/Office Name: Agency/Office Address:
5. Present Address: House No./Blk. No.
Street
Barangay
City/Municipality
Province
6. Previous Address: House No./Blk. No.
Street
Barangay
City/Municipality
7. Date of Birth:
Province
8. Civil Status:
9. Sex:
mm/dd/yyyy
10. Date of Marriage:
11. Nos.: mm/dd/yyyy
12. Highest Educational Attainment
Mobile
Educational Attainment
Period Attended
Educational Attainment
High School
Vocational
College
Post Graduate
Landline
Period Attended
TO BE ACCOMPLISHED BY THE RECEIVING CLERK Valid Identification Card presented by the APPLICANT Type
ID Number
Issuing Agency/Company
Valid Identification Card presented by the REPRESENTATIVE Type
ID Number
Issuing Agency/Company
THIS FORM IS NOT FOR SALE. REPRODUCTION IS ALLOWED. THIS CAN ALSO BE ED THRU THE OMBUDSMAN WEBSITE AT www.ombudsman.gov.ph
Page 1 of 2
Republic of the Philippines Office of the Ombudsman Agham Road, Diliman, Quezon City REQUIREMENTS:
1. Duly accomplished Application for Ombudsman Clearance (OMB Form 1) and any valid ID 2. Photocopy of service record and death certificate for death claims purposes 3. Payment of clearance fee
APPLICATION FOR OMBUDSMAN CLEARANCE CONFORME: By g below, I am agreeing to the Ombudsman and giving my consent to the collection and processing of my personal data in accordance thereto. _____________________________________________ Signature of Client Over Printed Name
PURPOSE OF CLEARANCE : Please indicate the number of copies in the appropriate box. Clearance Fee P100.00
Clearance Fee P200.00
CDD
Expiration of Term
Reversion
Awards, please specify:
Death Claim
GSIS Claims
Separation (Date)
Bar Exam
Guarantorship
Scientific Career System
Disability Retirement
Rationalization
CES Eligibility
Leave Application
Study Grant
Discharge
Resignation (Date)
CESO Rank
Loan Application
SUC Presidency
Dropped from the Roll
Retirement (Date)
Change of Name (Specify Name):
End of Contract (Date)
Commissionship
Nomination
UN Mission
End of Term (Date)
TPPD
Completion of Residency
Recognition
Visa
Expiration of Appointment
Training
Requirement by JBC, CSC, CESB, Office of the
Clearance Fee P150.00
Court Requirement
President, PRC, GOCC, DFA, DOLE, BI, LTO, NBI,
Appointment
Grant of Benefits
Reappointment
Extension of Service
PNP & other agencies: (Please specify agency)
Confirmation
Lateral Entry
Reemployment
Foreign Travel
Employment
Promotion
Transfer
Free and Accepted Masonry
Foreign Assignment
Schooling
ProcessingClearance Fee P1,000.00 Fee P1,000.00
Clearance Fee P500.00 Bidding Requirements
Scholarship
Fidelity Bond
Permit to Carry Firearms
Firearm License
MODE OF PAYMENT: Please one. Cash
SM, Hypermart, Savemore
Landbank
Postal money order payable to "Office of the Ombudsman Clearance Fees"
MODE OF RELEASE : Please one. pick-up at OMB office personally authorized representative
prepaid private courier*
regular mail
*applicant shall provide prepaid envelope except if paid thru SM
office address present/home address
APPLICANT'S INFORMATION: (Please PRINT legibly. Write "N/A" if not applicable) 1. Name of Applicant: First Name
Middle Name
Last Name
Suffix i.e, Jr.
3. If married, mother's maiden surname (for female applicant)
2. Current Position: 4. Agency/Office Name: Agency/Office Address:
5. Present Address: House No./Blk. No.
Street
Barangay
City/Municipality
Province
6. Previous Address: House No./Blk. No.
Street
Barangay
City/Municipality
7. Date of Birth:
Province
8. Civil Status:
9. Sex:
mm/dd/yyyy
10. Date of Marriage:
11. Nos.: mm/dd/yyyy
12. Highest Educational Attainment
Mobile
Educational Attainment
Period Attended
Educational Attainment
High School
Vocational
College
Post Graduate
Landline
Period Attended
TO BE ACCOMPLISHED BY THE RECEIVING CLERK Valid Identification Card presented by the APPLICANT Type
ID Number
Issuing Agency/Company
Valid Identification Card presented by the REPRESENTATIVE Type
ID Number
Issuing Agency/Company
THIS FORM IS NOT FOR SALE. REPRODUCTION IS ALLOWED. THIS CAN ALSO BE ED THRU THE OMBUDSMAN WEBSITE AT www.ombudsman.gov.ph
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