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