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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