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Application For Ombudsman Clearance (Omb Form 1) : Republic of The Philippines Office of The Ombudsman

This document is an application form for an Ombudsman clearance from the Republic of the Philippines Office of the Ombudsman. The form requests information such as the applicant's name, address, date of birth, agency/office, and payment details. It states that the applicant declares the information provided is true and correct and requests the Ombudsman's office to issue a clearance. The applicant also agrees to the Ombudsman's privacy policy by signing. Spaces are also provided if the application is filed by an authorized representative of the applicant or deceased person.

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MissEu Ferrer Montericz
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495 views

Application For Ombudsman Clearance (Omb Form 1) : Republic of The Philippines Office of The Ombudsman

This document is an application form for an Ombudsman clearance from the Republic of the Philippines Office of the Ombudsman. The form requests information such as the applicant's name, address, date of birth, agency/office, and payment details. It states that the applicant declares the information provided is true and correct and requests the Ombudsman's office to issue a clearance. The applicant also agrees to the Ombudsman's privacy policy by signing. Spaces are also provided if the application is filed by an authorized representative of the applicant or deceased person.

Uploaded by

MissEu Ferrer Montericz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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OMB Form 1 - December 2019

STAMP HERE

Republic of the Philippines


Office of the Ombudsman

APPLICATION FOR OMBUDSMAN CLEARANCE (OMB Form 1)

NUMBER OF ORIGINAL COPIES REQUESTED: NUMBER OF CERTIFIED COPIES REQUESTED:

MODE OF PAYMENT: Please check (√) the appropriate box.

Cash Postal Money Order payable to Others, please specify: Exempted


"Payable to Office of the Ombudsman First time jobseeker
Clearance Fees" Indigent

MODE OF RELEASE: Please check (√) the appropriate box.

pick-up at regular mail private courier


OMB office office * to be provided by the Applicant
*prepaid envelope to be provided by the applicant
present/home address

APPLICANT'S INFORMATION: Please PRINT legibly. Write "N/A" if not applicable

Last Name First Name Middle Name

If married, mother's
maiden surname
Current Position: (for female applicant)

Agency/Office Name:

Agency/Office Address:
Zip Code

Present Address:
House No./Blk. No. Street Name Barangay

City/Municipality Province Zip Code

Date of Birth: Contact Nos.: Sex:


mm/dd/yyyy Mobile/Landline

I declare that the answers given above are true and correct to the best of my knowledge and belief. I respectfully request your good office to issue a clearance in my favor.

By signing below, I agree to the Ombudsman Privacy Policy and give my consent to the collection and
processing of my personal data in accordance thereto.

Signature Over Printed Name of Client Date

IN CASE APPLICATION IS FILED BY AUTHORIZED REPRESENTATIVE OR REQUESTER IN BEHALF OF THE DECEASED PERSON

Last Name First Name Middle Name

Relation to Applicant/Deceased
Signature Over Printed Name of Client Date

TO BE ACCOMPLISHED BY THE RECEIVING PERSONNEL

Amount Paid:
OR Number:
Date of Payment:
Signature of Receiving Personnel:

THIS FORM IS NOT FOR SALE. THIS CAN ALSO BE DOWNLOADED THRU THE OMBUDSMAN WEBSITE AT www.ombudsman.gov.ph

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