REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF JUSTICE


NATIONAL BUREAU OF INVESTIGATION
REFERENCE NUMBER
NBI CLEARANCE APPLICATION FORM
MP0AY9RFAR
Friday Sep 16, 2022 PM
Valid Until Oct 01, 2022
()
APPLICANT TYPE 1. ID PRESENTED 2. PURPOSE TYPE 3. PURPOSE APPLICATION
NEW PHILHEALTH|06-025451903-3 LOCAL MULTI-PURPOSE CLEARANCE

BASIC INFORMATION
5. FAMILY NAME 6. HUSBAND FAMILY NAME (FOR MARRIED WOMAN ONLY)
ESPIRITU -

7. GIVEN NAME 8. MIDDLE NAME

CHRISTIAN TABARREJO

9. NICKNAME 10. OTHER NAME/ALSO KNOW AS

CHAN -

11. DATE OF BIRTH 12. BIRTH PLACE

08/22/1999 AGANI ALCALA CAGAYAN

13. CITIZENSHIP 14. GENDER 15. CIVIL STATUS

FILIPINO MALE SINGLE

16. SPOUSE 17. BIRTH PLACE

- -

18. PRESENT ADDRESS

ZONE 1

19. CONTACT NUMBER 20. EMAIL ADDRESS 21. IDENTIFYING MARKS

09750062949 christianespiritu031@gmail.com -

ADDITIONAL INFORMATION
22. HEIGHT 23. WEIGHT 24. COMPLEXION 25. RELIGION
163 63 FAIR ROMAN CATHOLIC

26. EDUCATIONAL ATTAINMENT 27. OCCUPATION

COLLEGE GRADUATE UNEMPLOYED

PARENTS INFORMATION

28. NAME OF FATHER 29. FATHER BIRTH PLACE

FLORENTINO ESPIRITU AGANI ALCALA CAGAYAN

30. NAME OF MOTHER 31. MOTHER BIRTH PLACE

FREMALYN ESPIRITU AGANI ALCALA CAGAYAN

I certify that I have read and understood all the questions set forth in this application and answer I have furnished on this form are true and correct to the best acknowledge and belief. I understand that any false or misleading statement is FALSIFICATION PUNISHABLE UNDER ARTICLE 171 & 172 OR REVISED PENAL CODE

________________________________ ________________________________

36. DATE 37. SIGNATURE

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