BI FORM 2015-08-001B Rev 0

Republic of the Philippines

Department of Justice
BUREAU OF IMMIGRATION

EMIGRATION CLEARANCE CERTIFICATE

No. ______________

This is to certify that (Last Name, First Name, Middle Name) ,

_______,
(Age) __________,
(Gender) _____________________________,
(Citizenship/Nationality) whose photograph,
signature and thumbprints appear below, about to depart from the Philippines for
TEMPORARY/PERMANENT residence abroad is hereby issued this certificate in
accordance with the provision of Section 22(a) of the Philippine Immigration Act of
1940, as amended, allowing his/her departure from this country on or before
___________________________.
Date [Day-Month-Year e.g 01 January 1990]

Manila, Philippines, __________________________.

Date [Day-Month-Year e.g 01 January 1990]

Attach your 2x2 colored photograph

with white background using
permanent glue in the
photograph box.
The photograph must be taken
FOR THE COMMISSIONER
within the last three (3) months BY:
from the date of application.
A scanned photograph is not
allowed. A photograph of the
applicant wearing eyewear (i.e. _______________________________________
sunglasses, colored contact lenses, Alien Control Officer
etc.) or headwear is not acceptable.

____________________ Date and status of latest admission:

Signature of Applicant ______________________________
Expiry of authorized stay:
______________________________
IC No. ________________________

Official Receipt No._______________

Date __________________________
ACR No. _______________________
ICR No. _______________________
Left Right
Thumbmark Thumbmark CRTV/CRPE No. _________________

Note: At the time of departure, this certificate must be surrendered to the Immigration
Officer at the Port of Departure.