BI FORM 2013-08-02A Rev 0 ANNUAL REPORT APPLICATION FORM

This document may be reproduced and is NOT FOR SALE Attach your 2x2 colored photograph with white background using permanent glue in the photograph box. The photograph must be taken within the last thirty (30) days from the date of application. A scanned photograph is not allowed. Headwears or eyewear (i.e. sunglasses, colored contact lenses, etc.) on the photograph submitted is prohibited.

Republic of the Philippines Department of Justice BUREAU OF IMMIGRATION

ANNUAL REPORT FORM (FOR ALL TYPES OF VISA except EO 324/RA 7919) Instructions: 1. Personally accomplish this form; 2. Use black ink ballpen only; 3. Print neatly and legibly; 4. Do not leave any space blank. Write N/A if not applicable. Improperly/Incompletely filled-out form will not be acted upon. TYPE OF VISA ACR I-CARD NUMBER Other Names/Aliases I. APPLICANTS PERSONAL INFORMATION (as appearing on the passport) Last Name Middle Name

Date of Birth [DD-MMM-YYYY e.g. 01 JAN 1990] First/Given Name Age Citizenship/Nationality Marital Status Single Other Names/Aliases Separated Passport Number Date of Issuance [DD-MMM-YYYY e.g. 01 JAN 1990] Date of Birth [DD-MMM-YYYY e.g. 01 JAN 1990] Age Citizenship/Nationality Marital Status Single Separated Passport Number Expiry Date/Valid Until [DD-MMM-YYYY e.g. 01 JAN 1990] Date of Issuance [DD-MMM-YYYY e.g. 01 JAN 1990] Residential Address House/Unit No., Street, Subdivision Barangay, Municipality/City Province, Zip Code Email Address Gender Male Female Type of Visa ACR I-Card Number ICR Number Place of Marriage Date of Marriage [DD-MMM-YYYY e.g. 01 JAN 1990] Gender Male Middle Name Female

Married Widowed

Annulled Divorced

Married Widowed

Annulled Divorced

III. A. PETITIONERS INFORMATION [for working/student visa holders] Name of Petitioner [Company/School]

Registration Number/Company TIN Number Primary Purpose [Write N/A if not applicable] Registered Address of Petitioner Room No., Floor No., Building, Street Barangay, Municipality/City Province, Zip Code Contact Number Name of Petitioners Representative [Company/School]

II. SPOUSES INFORMATION Last Name

First/Given Name

Page 1 of 4

BI FORM 2013-08-02A Rev 0 ANNUAL REPORT APPLICATION FORM Position in the Company

This document may be reproduced and is NOT FOR SALE Citizenship/Nationality Date of Birth [DD-MMM-YYYY e.g. 01 JAN 1990] Age Marital Status Single Separated Passport Number Gender Male Married Widowed Female Annulled Divorced

B. APPLICANTS OTHER INFORMATION [for working visa holders] [Write N/A if not applicable.] Position/Proposed Position Actual Monthly Gross Salary Expiration of Contract [DD-MMM-YYYY e.g. 01 JAN 1990] Alien Employment Permit [AEP] Number

Date of Issuance [DD-MMM-YYYY e.g. 01 JAN 1990] Expiry Date/Valid Until [DD-MMM-YYYY e.g. 01 JAN 1990] Type of Visa IV. A. PETITIONERS INFORMATION [for Immigrant/Temporary Resident Visa Holders] Last Name Email Address Spouses Name [include all aliases] First/Given Name

Middle Name

2 Last Name

Other Names/Aliases

First/Given Name

Middle Name Citizenship/Nationality ACR I-Card Number Type of Visa Residential Address House/Unit No., Street, Subdivision Barangay, Municipality/City Province, Zip Code B. APPLICANTS RELATIONSHIP TO THE PETITIONER Other Names/Aliases

Citizenship/Nationality Date of Birth [DD-MMM-YYYY e.g. 01 JAN 1990] Age Marital Status Single Separated Passport Number Date of Issuance [DD-MMM-YYYY e.g. 01 JAN 1990] Type of Visa Gender Male Married Widowed Female Annulled Divorced

V. DEPENDENT/S INFORMATION [including those residing abroad] NAME OF ALL LIVING CHILDREN (as appearing on the passport)

1 Last Name

First/Given Name Email Address Spouses Name [include all aliases] Middle Name

Other Names/Aliases

3 Last Name

Page 2 of 4

BI FORM 2013-08-02A Rev 0 ANNUAL REPORT APPLICATION FORM First/Given Name Type of Visa Email Address Middle Name

This document may be reproduced and is NOT FOR SALE

Spouses Name [include all aliases]

Other Names/Aliases

VI. PARENTS INFORMATION Father (as appearing on the passport) Last Name

Citizenship/Nationality Date of Birth [DD-MMM-YYYY e.g. 01 JAN 1990] Age Marital Status Single Separated Passport Number Date of Issuance [DD-MMM-YYYY e.g. 01 JAN 1990] Type of Visa Email Address Spouses Name [include all aliases] Gender Male Married Widowed Female Annulled Divorced

First/Given Name

Middle Name

Other Names/Aliases

Citizenship/Nationality Date of Birth [DD-MMM-YYYY] Marital Status Single Separated Passport Number Age

Married Widowed

Annulled Divorced

4 Last Name
Date of Issuance [DD-MMM-YYYY e.g. 01 JAN 1990] Type of Visa ACR I-Card Number Middle Name ICR Number

First/Given Name

Other Names/Aliases

Mother (as appearing on the passport) Last Name

First/Given Name Citizenship/Nationality Date of Birth [DD-MMM-YYYY e.g. 01 JAN 1990] Age Marital Status Single Separated Passport Number Citizenship/Nationality Date of Issuance [DD-MMM-YYYY e.g. 01 JAN 1990] Date of Birth [DD-MMM-YYYY] Age Gender Male Married Widowed Female Annulled Divorced Other Names/Aliases Middle Name

Page 3 of 4

BI FORM 2013-08-02A Rev 0 ANNUAL REPORT APPLICATION FORM Marital Status Single Separated Passport Number Date of Issuance [DD-MMM-YYYY e.g. 01 JAN 1990] Type of Visa ACR I-Card Number ICR Number Married Widowed Annulled Divorced

This document may be reproduced and is NOT FOR SALE

Specify the name(s) of deceased child(ren) and/or parent(s):

DO NOT FILL-OUT THIS PORTION

Received by: __________________________________ Signature over PRINTED NAME 2 Date Received: ________________________________ BI Office: ____________________________________

CERTIFICATION
I certify under oath that all the information in the form is truthful, complete and correct. I understand that I will be held liable under CA 613/RA 562/Revised Penal Code and my visa will be cancelled if any statement is false. In addition to the foregoing, I will be subject to deportation proceedings.

_______________________ Signature over Printed Name

Date

(DD-MMM-YYYY e.g. 01-JAN-1990)

Left Thumbmark

Right Thumbmark

SUBSCRIBED AND SWORN TO before me this _____day of ___________________________________, 20_____ affiant exhibiting his/her ACR I-Card No. and/or Passport Number _____________________________________ issued at ______________________________________ on ________________________.

Doc No. Book No. Page No. Series of

________________ ________________ ________________ ________________

Notary Public/ Administering Officer

Page 4 of 4