Barangay Clearance Application Form

BARANGAY CLEARANCE

Application Form

Control No.: Date Filed:

O.R. No.: Amount Paid:

I. Personal Information

📷
1x1 or
2x2 Photo

Last Name

First Name

Middle Name

Suffix (Jr./Sr./III)

Nickname / Alias

Date of Birth

Place of Birth

Age

Sex

Civil Status

Nationality

Religion

Occupation

Contact Number

Email Address

II. Address

Present Address (House No. / Street / Purok)

Barangay

Municipality / City

Province

How long residing in this barangay?

Permanent Address (if different from present)

III. Purpose of Application

Check all that apply:

IV. Emergency Contact

Contact Person

Relationship

Address

Contact Number

I hereby certify that all information given above are true and correct to the best of my knowledge and belief. I understand that any false statement or misrepresentation shall be grounds for denial or revocation of this clearance.

Signature over Printed Name / Applicant

Witness / Barangay Staff on Duty

For Official Use Only

Verified by

Date Verified

Cedula No.

Date / Place Issued

Clearance No.

Date of Issuance

Valid Until

Remarks

Punong Barangay