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Ombudsman's Clearance Form

This document is an application form for Ombudsman clearance from the Republic of the Philippines Office of the Ombudsman. It lists the requirements to apply, which include a completed application form, valid ID, and payment of the clearance fee. It requests information about the applicant such as name, position, agency, address, date of birth, and contact details. It also asks for the purpose of the clearance and mode of payment and release preferred. The final section is for recording details of the identification presented by both the applicant and any authorized representative.

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cedrick5sagun
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3K views2 pages

Ombudsman's Clearance Form

This document is an application form for Ombudsman clearance from the Republic of the Philippines Office of the Ombudsman. It lists the requirements to apply, which include a completed application form, valid ID, and payment of the clearance fee. It requests information about the applicant such as name, position, agency, address, date of birth, and contact details. It also asks for the purpose of the clearance and mode of payment and release preferred. The final section is for recording details of the identification presented by both the applicant and any authorized representative.

Uploaded by

cedrick5sagun
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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OMB Form 1-Application for Ombudsman Clearance Page 1 of 2

Republic of the Philippines


Office of the Ombudsman
Agham Road, Diliman, Quezon City

REQUIREMENTS: 1. Duly accomplished Application for Ombudsman Clearance (OMB Form 1) and any valid ID
2. Photocopy of service record and death certificate for death claims purposes
3. Payment of clearance fee

APPLICATION FOR OMBUDSMAN CLEARANCE


CONFORME:
By signing below, I am agreeing to the Ombudsman Privacy Policy and giving my consent to the collection and processing of my personal data in accordance thereto.
_____________________________________________
Signature of Client Over Printed Name
PURPOSE OF CLEARANCE : Please indicate the number of copies in the appropriate box.
Clearance Fee P100.00 Clearance Fee P200.00
CDD Expiration of Term Reversion Awards, please specify:
Death Claim GSIS Claims Separation (Date) Bar Exam Guarantorship Scientific Career System
Disability Retirement Rationalization CES Eligibility Leave Application Study Grant
Discharge Resignation (Date) CESO Rank Loan Application SUC Presidency
Dropped from the Roll Retirement (Date) Change of Name (Specify Name):
End of Contract (Date) TPPD Commissionship Nomination UN Mission
End of Term (Date) Completion of Residency Recognition Visa
Expiration of Appointment Training Requirement by JBC, CSC, CESB, Office of the
Clearance Fee P150.00 Court Requirement President, PRC, GOCC, DFA, DOLE, BI, LTO, NBI,
Appointment Grant of Benefits Reappointment Extension of Service PNP & other agencies: (Please specify agency)
Confirmation Lateral Entry Reemployment Foreign Travel
Employment Promotion Transfer Free and Accepted Scholarship
Foreign Assignment Masonry Schooling

Clearance Fee P500.00 ProcessingClearance Fee P1,000.00


Fee P1,000.00
Bidding Requirements Fidelity Bond Permit to Carry Firearms Firearm License
MODE OF PAYMENT: Please  one.
Cash SM, Hypermart, Savemore Landbank Postal money order payable to
"Office of the Ombudsman Clearance Fees"
MODE OF RELEASE : Please one.
pick-up at OMB office prepaid private courier* regular mail
personally *applicant shall provide prepaid envelope office address
except if paid thru SM
authorized representative present/home address
APPLICANT'S INFORMATION: (Please PRINT legibly. Write "N/A" if not applicable)
1. Name of Applicant:
First Name Middle Name Last Name Suffix i.e, Jr.
3. If married, mother's maiden surname
2. Current Position:
(for female applicant)

4. Agency/Office Name:

Agency/Office Address:

5. Present Address:
House No./Blk. No. Street Barangay

City/Municipality Province

6. Previous Address:
House No./Blk. No. Street Barangay

City/Municipality Province

7. Date of Birth: 8. Civil Status: 9. Sex:


mm/dd/yyyy

10. Date of Marriage: 11. Contact Nos.:


mm/dd/yyyy Mobile Landline

Educational Educational
12. Highest Educational Attainment Attainment
Period Attended
Attainment
Period Attended

High School Vocational

College Post Graduate

TO BE ACCOMPLISHED BY THE RECEIVING CLERK


Valid Identification Card presented by the APPLICANT Valid Identification Card presented by the REPRESENTATIVE

Type ID Number Issuing Agency/Company Type ID Number Issuing Agency/Company

THIS FORM IS NOT FOR SALE. REPRODUCTION IS ALLOWED. THIS CAN ALSO BE DOWNLOADED THRU THE OMBUDSMAN WEBSITE AT www.ombudsman.gov.ph

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