CHR Clearance Application Form Revision Date 24-01-2019
CHR Clearance Application Form Revision Date 24-01-2019
CHR Clearance Application Form Revision Date 24-01-2019
Computer Scanned or
COMMISSION ON HUMAN RIGHTS
Photocopy of picture will not
be accepted
APPLICATION FOR
CHR CLEARANCE / CERTIFICATION
Instruction:
A. Applicant must personally fill-up this application form.
B. Type or print legibly all necessary information.
C. Mark appropriate boxes with check “ ” mark.
D. Use additional sheet, if necessary.
1. Full Name:
_______________________________________________________________________________________
12. Contact Information: Telephone / Mobile Number: _______________________ Email: ____________________________
To be filled-up if Applicant is a member of PNP / AFP
13. Branch of Service: _______________________________ 14. Current Rank/Position: ____________________________
15. Identification Number: AFP Serial No.: ______________________________ PNP Badge No.: ______________________
16. Present Unit/Office Assignment: __________________________________________________________________________
17. Office Address: _______________________________________________________________________________________
_______________________________________________________________________________________
18. Contact Information: Telephone / Mobile Number: _______________________ Email: ____________________________
19. AFP/PNP/Other Official Assignment and Position Held: (Use additional sheet, if necessary)
Period
Position /Rank Office/Place of Assignment
From To
(to be filled-up by CHR Clearance Unit Personnel) Tracer No.: ____________________ Date Filed: ___________________
Claim Stub: (to be filled-up by CHR Clearance Unit Personnel) Note: In claiming your CHR Clearance / Certificate, please present the following:
1. Valid Identification Card
Name of Applicant: ___________________________________________ 2. Documentary Stamp (worth P15.00)
3. If thru a representative:
Date Filed: ____________________ Date Due: ____________________ a. Authorization Letter
b. Valid ID of Representative
CHR Clearance Unit Telephone No. (02) 282-1877
To be filled-up by the Applicant (either AFP/PNP member, Government employee, Private Individual or other Professional
20. Records of Administrative/Criminal Case(s), if any: (Use additional sheet, if necessary)
Case/Docket Number Case Classification / Description Date Filed Status
21. Record of Human Rights Education and In-Service Training Courses Attended: (Use additional sheet, if necessary)
Title of the Course Conducted by Date Conducted
_____________________________________________________
Signature over Printed Name of Applicant
Applicant’s Right
Thumb mark
Office I.D. No. :
Issued by:
Issued on:
Issued at:
, Philippines.
_____________________________________________________
Administering Officer