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OMB Form 1 - Application for Ombudsman Clearance (1)

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Marlo Bugayong
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73 views

OMB Form 1 - Application for Ombudsman Clearance (1)

Uploaded by

Marlo Bugayong
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Revised OMB Form 1 - March 2024

Republic of the Philippines


Office of the Ombudsman

1. APPLICATION WITHOUT COMPLETE DOCUMENTARY REQUIREMENTS AND PAYMENT WILL NOT BE PROCESSED.
2. PLEASE WRITE LEGIBLY, WRITE "N/A" IF NOT APPLICABLE AND SIGN THE APPLICATION FORM

APPLICATION FOR OMBUDSMAN CLEARANCE (OMB Form 1)

NUMBER OF ORIGINAL COPIES REQUESTED: 2


P150.00 per copy
APPLICANT'S INFORMATION:

MARLO GARCIA BUGAYONG M


First Name Middle Name Last Name Suffix Sex
(e.g., Jr. Sr. II, III etc.)

Date of Birth:
12/11/1993 If married, mother's maiden surname
mm/dd/yyyy (for female applicant)

Contact Nos.: 09293698347 Email Address: [email protected]


`

Current Position: Private Law Practice


Agency/Office Name: Bugayong Law Office (Under Renovation) From: Dec. 2023 To: Present

Agency/Office Address: 4 Mabini Street, Mangatarem, Pangasinan 2413


Zip Code

Present Home Address: Ponglo Muelag, Mangatarem, Pangasinan 2413


Zip Code
MODE OF PAYMENT: Please check (√) the appropriate box.

Cash Postal Money Order Others, please specify: Exempted


Payable to the "Office of the First time jobseeker
LANDBANK Link.BizPortal Ombudsman-Clearance Indigent
Fees" * One time exemption
and only for one original copy

MODE OF RELEASE: Please check (√) the appropriate box.

pick-up at OMB office registered mail


agency/office
courier service present home address
*prepaid envelope to be clearance delivery address __________________________________________________
provided by the applicant/client
w/ full delivery address

IN CASE APPLICATION IS FILED BY AUTHORIZED REPRESENTATIVE OR REQUESTER IN BEHALF OF THE DECEASED PERSON

Please check (√) the appropriate box.

Authorized Representative Requester in behalf of the Deceased Person

First Name Middle Name Last Name Suffix (e.g.,


Jr. Sr. II, III etc.)

Relation to Applicant/Deceased:
Signature Over Printed Name of Client Date

I declare that the answers given above are true and correct to the best of my knowledge and belief. I
respectfully request your good office to issue a clearance in my favor. By signing below, it is understood that
the personal information submitted will be used solely to provide the services requested, handled properly
and not shared with any unauthorized person in accordance with the Ombudsman Privacy Notice.

MARLO G. BUGAYONG 08/10/2024


Signature Over Printed Name of Applicant Date

TO BE ACCOMPLISHED BY CLEARANCE PERSONNEL

Control Number: Date & Time Received:


Date Filed: Due Date:
Mode of Filing: Date Assigned
Mode of Payment: Assigned Verifier:
Remarks: Name & Signature:

THIS FORM IS NOT FOR SALE. THIS CAN ALSO BE DOWNLOADED THRU THE OMBUDSMAN WEBSITE AT www.ombudsman.gov.ph

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