SPECIAL POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS:

I/We, __________________________________________, of legal age, Filipino/s and presently

residing at _________________________________, do hereby name, constitute and appoint,
______________________________, of legal age, Filipino, with address in the Philippines at
___________________________________________, to be our true and lawful Attorney-in-
Fact, for me/us and in my/our name, place and stead, to do and perform any or all of the
following acts, to wit:

1. To apply for and obtain certified copies of the Birth Certificate/s of: Name Date/Place of
Birth Relationship
_________________________ ____________________ _______________
_________________________ ____________________ _______________
_________________________ ____________________
_______________
and to have said documents authenticated, as appropriate, by the proper authentication
officers of the Philippine Statistics Authority and the Department of Foreign Affairs,
_________; (edit/remove if needed)

2. To represent me/us at the Department of Foreign Affairs in ____________, or in any of

the Regional Consular Offices for the purpose of the application/renewal/releasing of the
passport of ______name____________;

3. To collect or receive the aforementioned documents after the authentication thereof;

4. To represent me/us at the ____name of embassy____ Embassy for the visa application of
________________; (edit/remove if needed)

5. To execute and sign all documents which may be necessary or required for the above
purpose(s).

HEREBY GIVING AND GRANTING unto my said Attorney-in-Fact full power and authority
to do and perform any and every act and thing whatsoever requisite, necessary or proper to be
done in and about the premises as fully to all intents and purposes as I/we might or could do if
personally present. HEREBY RATIFYING AND CONFIRMING all that my/our said
Attorney-in-Fact shall lawfully do or cause to be done under and by virtue of these presents.

IN WITNESS WHEREOF, I/we have hereunto affixed my/our signature/s on this

___________________ in the City of _______________, Philippines.

__________________________ WITH MY CONFORMITY:

Principal
________________________
Attorney-in-Fact

SIGNED IN THE PRESENCE OF:

____________________________ ___________________________
Witness Witness
ACKNOWLEDGMENT

BEFORE ME, a Notary Public for and in the (Province/City/Municipality) of _____________

this __date__ personally appeared _____________ with competent proof of identity
_____________ issued on _____________ at _____________, known to me and to me known to
be the same person who executed the foregoing instrument , and (he/she) acknowledged to me
that the same is his/her free and voluntary corporate act and deed
WITNESS MY HAND AND SEAL this _____________ at _____________, Philippines.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of ______;