Department of JusticeBUREAU OF IMMIGRATIONMagallanes Drive, IntramurosManila 1002 TOURIST VISA EXTENSION FORM

( BI FORM RADJR-2012-04 )

This form may be reproduced and is NOT FOR SALE

Consolidated General Application Form for

Contact Number of Character Reference

Recommendation / Approval

Acting Chief, Visa Extension Section

Assessor

Date

Date

Address of Character ReferenceNo. Street, Subdivision, Brgy. Municipality/ City, Province, Zip Code

Weight (kg)Height (cm)

DIRECTIONS:

1. Mark appropriate boxes with ”X”. Indicate “N/A” if not applicable. Do not leave any space blank. Print all information legibly.2. Tourist Visa Extension Form not properly accomplished will be summarily denied.3. Giving of false information by applicant or his/her duly authorized representative will be basis for the summary denial of application.4. Only representatives duly accredited by the Bureau will be allowed to represent applicant.

CHECKLIST OF REQUIREMENTS:

1. Original Valid Passport;

2. Visa Extension Application Form (Form No. RADJR 2012-04);

3. Bureau of Immigration (BI) Clearance Certi�cate (to be issued

upon �ling of application).

Civil Status

Single Separated in Fact Divorced

Married Widower/ Widow

PERSONAL INFORMATION

CHARACTER REFERENCE

LAST TRAVEL INFORMATION

APPLICATION INFORMATION

No. of Monthsrequested

Other (specify)No. of Monthsstayed

Reason Pleasure Health With Valid Special Study Permit

Business With pending other visa application

Last Name

First Name / Given Name

Middle Name

Other Name / Alias / AKA

Name of Applicant

BI ACCREDITATION NUMBER NAME OF ACCREDITED AUTHORIZED REPRESENTATIVE

Country of Birth

Passport Number

Last Name, First Name Middle Initial

Address in the PhilippinesNo. Street, Subdivision, Brgy. Municipality/ City, Province, Zip Code

Address AbroadNo. Street, Subdivision, Village, City, State, Country, Zip Code

Citizenship / Nationality

Date of Birth [mm-dd-yyyy] Gender

Expiry Date [mm-dd-yyyy]

Place of Issuance

Flight Number

Date of Arrival [mm-dd-yyyy]

Last day of authorized stay[mm-dd-yyyy]

OPS / Derogatory Check

Implementor

Date

Chief, IRD

Date

Implementation Approved for theCommissioner

C E R T I F I C A T I O N

Date: _______

ApplicantSignature over Printed Name

I HEREBY CERTIFY under oath that all the information in this application form, are true and correct base on my own personal knowledge and on authentic documents in my possession. I furthermore warrant that I have complied with all the requirements of the Bureau of Immigration with respect to this application. I understand that my application can be summarily denied by the Bureau if it �nds any statement herein to be false, if any document submitted are found to have been falsi�ed, or if I fail to comply with all the requirements with respect to my application without prejudice to whatever action the Bureau of Immigration shall take in accordance with applicable laws of the Republic of the Philippines.

III. APPLICANT’S TRAVEL INFORMATION

Last Name, First Name, M.I.

Contact Number

Passport Number

Expiry Date / Valid Until

Place of Issue

Flight Number

Date of Last Arrival [mm-dd-yyyy]

Name of Authorized Representative

Accreditation Travel Agency / Law O�ce

BI Accreditation Number

Contact Number

Contact Address

Signature

ACR I-CARD WILL ONLY BE RELEASED UPON COMPLIANCE / SUBMISSION OF THE FF:

1. If applicant is a minor, either parent may claim the ACR I-card and present indenti�cation.

2. If by a travel agent or law �rm, submit photocopy of the BI-Accreditation ID card.

3. If claimed by other person, must present special power of attorney (SPA).

4. Attach photocopy of passport bio page of the ACR I-card holder.

Subject: printed name over signature

Claimant: printed name over signature

[ Please call 527-7557 to check the status of your application ]

VI. ACR I-CARDACR Number

Certificate of Residence Number

Issue Date [mm-dd-yyyy]

Valid Until [mm-dd-yyyy]

Received / Recommended by:

Reviewed by:

Approved by:

DO NOT FILL-UP THIS PORTIONApplication Number

IV. PETITIONER’S INFORMATIONName of Petitioner

Contact Number

Registered Address of PetitionerNo. Street, Subdivision, Brgy. Municipality/ City, Province, Zip code

C E R T I F I C A T I O N

Date: _____________

Notary Public / Administering Officer

PetitionerSignature over Printed Name

ApplicantSignature over Printed Name

Republic of the Philippines)City/ Municipality of_________) S.S.

Subscribe and sworn to before me this_____day_____________________,_____affiant exhibiting his / her CTC, ACR,Passport number________________________________ issued at ______________________________ on ________________________ .

I HEREBY CERTIFY under oath that all the information in this application form consisting of two (2) pages, including the page on which this certi�cation is written, are true and correct base on my own peresonal knowledge and on authentic documents in my possession. I furthermore warrant that I have complied with all the require-ments of the Bureau of Immigration with respect to this application and that I submitted duly certi�ed copies / authenticated documents issued under the o�cial seal of the o�cer having legal custody of their originals in the Philippines and foreign documents with their o�cial English translation, duly authenticated by the consul / embassy o�cial in the consular o�ce of the Philippines in the foreign country where such documents were issued. I understand that my application can be summarily denied by the Bureau if it �nds any statement herein to be false, if any document submitted are found to have been falsi�ed, or if I fail to comply with all the requirements with respect to my application / petition without prejudice to whatever action the Bureau of Immigration shall take in accordance with applicable laws of the Republic of the Philippines.

Doc. No.Book No.Page No.Series of.

Character Reference in the Philippines

Residential Address in the PhilippinesNo. Street, Subdivision, Brgy. Municipality/ City, Province, Zip Code