Tourist Visa Extension Form 2014 Page 2

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BI FORM 2014-00-004 Rev 0
This document may be reproduced and is NOT FOR SALE
CONSOLIDATED GENERAL APPLICATION FORM
TOURIST VISA EXTENSION
FOR
IV. Character References in the Philippines
Last Name, First/Given Name, Middle Name
1
Residential Address in the Philippines
House/Unit No., Street, Subdivision/Village
Barangay, Municipality/City
Province, Zip Code
Contact Number(s) in the Philippines
Landline
Mobile
Last Name, First/Given Name, Middle Name
2
Residential Address in the Philippines
House/Unit No., Street, Subdivision/Village
Barangay, Municipality/City
Province, Zip Code
Contact Number(s) in the Philippines
Landline
Mobile
C E R T I F I C A T I O N
I/We certify that: (1) All the information in the application is truthful, complete and correct; (2) All documents
are authentic and were legally obtained from the corresponding government agencies or private entities; (3) I/We
understand that my/our application may be summarily denied if: (a) Any statement is false; (b) Any document
submitted is falsified; or (c) I/We fail to comply with all the BI requirements without prejudice to whatever action the
BI may take; and (4) I/We have not filed this or any similar application before any office of the Bureau.
______________________________________
_____________________________________
Date [DD-MMM-YYYY e.g. 01 JAN 1990]
Applicant’s Signature over Printed Name
Recommending Approval
_____________________________
________________________________
Chief, Visa Extension Section
Date [DD-MMM-YYYY e.g. 01 JAN 1990]
OPS / Derogatory Check
Implementation
Approved/Disapproved
________________________________
____________________________
__________________________
Assessor
Implementor
Commissioner or Authorized
Representative
________________________________
____________________________
__________________________
Date
Date
Date
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