IJRTR Facility Visit Request ‘Visitor Personal Information T_[ Last Namever nyo RAMIRO| 2_[ Given Name MARIA CELERINA 3. | Date of Birth-oomurn 28/05/1960 4_ [Place of Birth Philippines | Nationalityies) Philippines 2 © | Gender Male[ J Female [x] 7__[nstitution Philippine Nuclear Research Institure 8_[ Position Head, Planning Section 9_| Passport Number ‘©E0020956 TO | Passport Place of Issuance | Manila 11 [Passport Date——-of | 21/05/2014 Issuance-poawrny= 1p | Passport Expiry | 11172015 Date-ppanevm= Visitor Home Address 20 Nobel St, Filinvest Homes 2, Batasan Hills, Quezon City, Philippines As; Postal/Zip Code 1126 Tel +63-9166780192 Visitor Work Address Commonwealth Avenue, Diliman, Quezon City, Philippines Postal/Zip Code 1100 \ Tel +632-9298011 to 19 Fax: $632-9201686 Email memramiro(@pnri:dost gov.ph TRIR Facility Visit Information 15 | Date of Visit-pomwnny™ 227022015 16 | Duration of Visit all day Purpose of Visit '7| Tour of facility with JUST for 2015 New Nuclear International Conference Thereby certify that the information given are true and correct ye—| ‘MARIA CELERINA ako. Feb 12, 2015 Lara, ‘Applicant Name Application Date ‘Signature FOR Official Use ONLY JAEC Security Department | Clear [} NotCiear! I ‘Commissioner in Charge | Approved [] ‘Not Approved [] Annex 9: IRTR visitor application form (for International visitors)