REQUEST / APPLICATION FOR SUBIC-CLARK

2X2 WORKING VISA (WV)

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Please check: PRINCIPAL WITH DEPENDENT
New Application X Renewal/Extension

The undersigned hereby requests for issuance of a Subic-Clark Working Visa with special multiple entry
privileges and with exemptions from exit clearance certificates, re-entry permits and special return
certificate pursuant to Memorandum of Agreement and Joint Memorandum No. 01-2009.

THOMAS RUMMER
First Name Middle Name Last Name Signature

Age 53 Sex (please check) Male X Female

Philippine Address/Residence Tel. No. 0977 777 7857
6722 ERIKA STREET, SUNSET VALLEY MANSIONS, BRGY. CUTCUT, ANGELES CITY

Nationality GERMAN Civil Status (Single, Married, etc.) MARRIED

Passport No. C4JHPVR89 Issued at SHANGHAI
Issued On 5-Sep-11 Valid Until 4-Sep-21

Employing Locator / Company In Freeport Zone. AVANTI GARAGE DOOR OPENERS, INC.
Locator's Address UNIT 25A1 & EXTENSION A1, PHILEXCEL BUSINESS PARK, CFZ, PAMPANGA
EMPLOYMENT:
POSITION/S: SENIOR CONSULTANT

Occupation Code:
Place of Assignmen CLARK FREEPORT ZONE
E-mail Address: Tel. No.
NATURE OF BUSINESS: ______________MANUFACTURE OF AUTOMATIC GARAGE DOOR OPENERS

DEPENDENTS ACCOMPANYING THE PRINCIPAL IN THE PHILIPPINES

Name Age Sex Nationality
Spouse N/A
Children N/A
DOCUMENTARY REQUIREMENTS FOR THE WORKING VISA:

FOR NEW APPLICATION, the following documents [original] in support of these statements are submitted:
a) Alien Employment Permit (AEP) issued by the Department of Labor and Employment Region III;
b) Affidavit of Support/Guarantee executed by an authorized officer of the locator;
c) NBI Clearance

Requirements for dependents accompanying the Special Subic Clark Working Visa (WV) applicant
a) Authenticated/Notarized Birth and/or Marriage Certificates for dependents and/or spouse;
b) NBI Clearance for dependents who are 18 years old and above;

FOR RENEWAL/EXTENSION, the following documents [original] are submitted in compliance with the
requirements:
a) Extended Alien Employment Permit (AEP)
b) Application and Visa Processing Fee
Zone Authorities reserve the right to impose additional requirements it deems necessary to process this
application.