Direct Legal RePresentation

Application Form
Form 1B (Direct Legal Representation Application Form)
FILE DETAIL5: (To be filled bv Regional Legal Officer) 2X2 PHOTO

Date Time File No.

I. APPLICANT'S PERSONAL INFORMATION:

1. Name:
(Surname) (First Name) (Middle Name) (Qualifier)
(Rank)

3. Civil Status: 4. Sex:

2. Age:

5. Offtceftjnit:

6. Home Address:

II. CHARGE/S:
Criminal Case: Offense(s)/Charge(s):

Docket No: CouTUOCP/OPP:

Administrative Case: Charge(s):

Docket ilo: Disaptinary AttthoritY:

Civil Caee: Titte of ease

Docket No: Court:

III. STATUS OF THE APPLIGANT:

Under preventive susPension Under recognize
Under regtrietive a.tstodY Under suspension
Under detention Active Duty
Posted bail Others (Pls specifY)

IV. BRIEF STATEMENT OF THE CASE;

V. DOCUMENTARY REQUIREMENTS:
Duty Status
HOINIR Cerffication that case is service connected
Sll Report
Lette#De*ail Grders
Information, Complaint, Charge Sheet
Other Relevant Documents (Pls specify

VI- DECLARATION:

I declare under oath that this Direct Legal Representation Application Form has been
accomplished by me, and this is true, correct, and complete statement. I authorize the
Regional Legal Service/authonzed representative to venfyfualidate the content stated
herein. ltrust that this information shall remain confidential.

Badge No.
SIGNATURE Date Accomplished