Department of JusticeBUREAU OF IMMIGRATIONMagallanes Drive, IntramurosManila 1002

I. APPLICATION INFORMATION

II. APPLICANTS PERSONAL INFORMATION

Accreditation Number

Name of Authorized RepresentativeLast Name

NON-IMMIGRANT VISA AND SPECIAL WORK PERMITEXCEPT STUDENT VISA AND SSP ( BI FORM RADJR-2012-02 )

Consolidated General Application Form for

Conversion Extension Permit Inclusion

Last Name

First Name / Given Name

Middle Name

Other Name / Aliases

Spouse / Wife / Husband

Name of Applicant

Name of Children and Date of Birth

Last Name

Name (use additional sheet if necessary)

Date of Birth [ mm-dd-yyyy ]

First Name / Given Name

Middle Name

Other Name / Alias

Country of Birth

Non-Immigrant Visa / Permit Applied for

Citizenship / Nationality

Residential Address in the PhilippinesNo. Street, Subdivision, Brgy. Municipality/ City, Province, Zip Code

Contact Number

Address AbroadNo. Street, Subdivision, Village, City, State, Country, Zip Code

Given Name

Present Immigration Status

Last Day of Authorized Stay [mm-dd-yyyy]

Name

Date of Birth [ mm-dd-yyyy ]

Date of Birth [mm-dd-yyyy] Gender

Male Female

Nature of Application

Type of Visa Application

Method of Application

Attach your 2 x 2 colored photograph using permanent glue

in the photograph box.The photograph must have been

taken not more than three (3) months from the date of this application.

Scanned photographs are not allowed.

Civil Status

Weight (kg)

Height (cm)

Last Name, First Name, M.I.

Contact Number

Character Reference in the Philippines

Residential Address in the PhilippinesNo. Street, Subdivision, Brgy. Municipality/ City, Province, Zip Code

Personal Authorized Representative

Applicants Name:

ACR Number: Visa Type:

APPLICANTS ACR I-CARD CLAIM STUB

[ IF ACR I-CARD IS CLAIMED BY OTHER PERSON, PLEASE SEE REVERSE SIDE FOR INSTRUCTIONS ]

C E R T I F I C A T I ON

Date: _____________

Notary Public / Administering Officer

PetitionerSignature over Printed Name

ApplicantSignature over Printed Name

Republic of the Philippines)City/ Municipality of_________) S.S.

Subscribe and sworn to before me this_____day_____________________,_____affiant exhibiting his / her CTC, ACR,Passport number________________________________ issued at ______________________________ on ________________________ .

VI. ACR I-CARDACR Number

Certificate of Residence Number

Issue Date [mm-dd-yyyy]

Valid Until [mm-dd-yyyy]

I HEREBY CERTIFY under oath that all the information in this application form consisting of two (2) pages, including the page on which this certication is written, are true and correct base on my own peresonal knowledge and on authentic documents in my possession. I furthermore warrant that I have complied with all the require-ments of the Bureau of Immigration with respect to this application and that I submitted duly certied copies / authenticated documents issued under the ocial seal of the ocer having legal custody of their originals in the Philippines and foreign documents with their ocial English translation, duly authenticated by the consul / embassy ocial in the consular oce of the Philippines in the foreign country where such documents were issued. I understand that my application can be summarily denied by the Bureau if it nds any statement herein to be false, if any document submitted are found to have been falsied, or if I fail to comply with all the requirements with respect to my application / petition without prejudice to whatever action the Bureau of Immigration shall take in accordance with applicable laws of the Republic of the Philippines.

Doc. No.Book No.Page No.Series of.

Name of Authorized Representative

Accreditated Travel Agency / Law Oce

BI Accreditation Number

Contact Number

Contact Address

Signature

ACR I-CARD WILL ONLY BE RELEASED UPON COMPLIANCE / SUBMISSION OF THE FF:

1. If applicant is a minor, either parent may claim the ACR I-card and present indentication.

2. If by a travel agent or law rm, submit photocopy of the BI-Accreditation ID card.

3. If claimed by other person, must present special power of attorney (SPA).

4. Attach photocopy of passport bio page of the ACR I-card holder.

Subject: printed name over signature

Claimant: printed name over signature

[ Please call 527-7557 to check the status of your application ]

V. APPLICANTS TRAVEL INFORMATIONPassport Number

Expiry Date / Valid Until

Place of Issue

Flight Number

Date of Last Arrival [mm-dd-yyyy]

III. PETITIONERS INFORMATION

Name of Petitioners Representative

IV. APPLICANTS OTHER INFORMATION

Name of Petitioner

Registration Number

Primary Purpose

Contact Number

Position in the Company

Proposed Position

Expiration of Contract

Actual Gross Monthly Salary

AEP Number

Expiry Date / Valid Until

Registered Address of PetitionerNo. Street, Subdivision, Brgy. Municipality/ City, Province, Zip code

Received / Recommended by:

Reviewed by:

Approved by:

DO NOT FILL-UP THIS PORTIONApplication Number