APPLICATION FOR IMMIGRANT VISA

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FOREIGN SERVICE OF THE PHILIPPINES PHILIPPINE CONSULATE GENERAL CHICAGO, IL U.S.A.

APPLICATION FOR IMMIGRANT VISA

REVISED 23 JANUARY 2008 (USA)

122 S. MICHIGAN AVE. SUITE 1600, CHICAGO, IL 60603 Tel. no. (312) 583-0621 Fax no. (312) 583-0647 Website: www.chicagopcg.com

FA FORM NO. 3

PLEASE TYPE OR PRINT ANSWERS LEGIBLY IN THE SPACES PROVIDED (IF NOT APPLICABLE WRITE (N/A)

11a. TRAVEL DOCUMENT TYPE 11b. PASSPORT / TRAVEL DOCUMENT NUMBER

11d. DATE OF ISSUE (dd/mm/yyyy)

11c. PLACE OF ISSUE (city, state or province,country)

11e. DATE OF EXPIRY (dd/mm/yyyy)

15. HOME ADDRESSES FOR THE PAST 5 YEARS*

(include apartment number, street, city, state or province, postal zone and country)

16. CURRENT HOME TELEPHONE NUMBER 17. E-MAIL ADDRESS

18a. PRESENT OCCUPATION / RANK / POSITION

19. WORK ADDRESS (include no., street, city, state or province, postal zone, country)

20. WORK TELEPHONE NUMBER 21. WORK FAX NUMBER

IMMIGRANT VISA NO.

FOR OFFICAL USE ONLY

IMMIGRANT VISA CLASSIFICATION

Non-Quota Immigrant under Section _______________ of the Philippine Immigration Act of 1940 as amended.

DATE OF ISSUE VISA SHEET NO.

11f. VISA REQUESTED

13. INTENDED PORT OF ENTRY

22. REFERENCES AND/OR IMMEDIATE RELATIVES IN THE PHILIPPINES NAME ADDRESS

14. EXPECTED DATE OF ARRIVAL IN THE PHILIPPINES QUOTA IMMIGRANT

NON-QUOTA IMMIGRANT

PASSPORT TRAVEL DOCUMENT 10. IF MARRIED, NAME AND ADDRESS OF SPOUSE

Quota Immigrant

Quota No. _____________________

18b. Since

APPLICANT'S PHOTOGRAPH 2 in. x 2 in.

ADDRESS INCLUSIVE DATES

1. NAME AS WRITTEN IN PASSPORT

6. CITIZENSHIP

7. DATE OF BIRTH (dd/mm/yyyy)

5. SEX

MALE FEMALE

MARRIED

SINGLE WIDOWED DIVORCED

9. CIVIL STATUS

2. LAST NAME (surname or family name)

3. FIRST NAME (all given names)

4. MIDDLE NAME

8. PLACE OF BIRTH (city, state or province, country)

PROCESSOR ENCODER

VISA APPROVED/DENIED BY

CASHIER

RECEIVER LOL

SCRIPTER

O.R. NUMBER FEE

SERVICE NO.

1. Picture taken within the past 6 months

2. Front View 3. Without eyeglasses

4. Name and Signature on front of photograph

SEPARATED

12. SUPPORTING DOCUMENTS

Staple or paste photo here

RELATIONSHIP

DATE OF EXPIRY

VISA ISSUED TO

CITIZENSHIP

BEARER'S TRAVEL DOCUMENT

Type ___________________________________

No. ___________________________________

Date of Isssue __________________________

Date of Expiry __________________________

Issuing Authority _______________________

_______________________________________

23. DATE OF APPLICATION 24. SIGNATURE OF APPLICANT

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34.

28. ON WHAT BASIS DO YOU CLAIM TO BE A

I understand that I may enter the Philippines at the port of entry designated by the Philippine Immigration Authorities under the conditions imposed by those authorities.

Signature of Applicant Over Printed Name

SUBSCRIBED AND SWORN to before me this day of , CY

Consul of the Republic of the Philippines 29. HAVE YOU EVER BEEN CONVICTED OF ANY CRIME? YES ( specify crime and date of conviction ) NO

32. HOW WILL YOU SUBMIT THIS APPLICATION?

PERSONAL MAIL / COURIER TRAVEL AGENCY / REPRESENTATIVE

30. HAVE YOU EVER BEEN REFUSED ANY KIND OF VISA FOR THE PHILIPPINES, DENIED ADMISSION INTO, DEPORTED OR REMOVED AT GOVERNMENT EXPENSE FROM THE PHILIPPINES? YES ( state circumstances and date of refusal/denied admission/deportation/removal ) NO

FOR OFFICIAL USE ONLY

31. HAVE YOU EVER BEEN INSTITUTIONALIZED FOR ANY MENTAL DISORDER?

33. DO YOU HAVE ANY PHYSICAL DEFECT OR CONTAGIOUS DISEASE?

YES ( state particulars and date of institutionalization) NO

YES ( state defect or disease and other particulars) NO

Notary Public

TRAVEL DOCUMENT RELEASED TO

DATE RECEIVED / MAILED MAIL/COURIER TRACKING NO.

PREFERENCE QUOTA IMMIGRANT NON-QUOTA IMMIGRANT?

Name of Travel Agency / Authorized Representative 27. ADDRESS IN THE PHILIPPINES WHERE THE APPLICANT INTENDS TO SETTLE (include apartment number, street, city, state or province, postal zone ) 25. OCCUPATION 26. NAME AND ADDRESS OF EMPLOYER IN THE PHILIPPINES

,

I solemnly swear under penalty of law that the foregoing statements are true and correct and the attached supporting documents are authentic.

at .

.

REMARKS ^{Doc. No.}

Service No.

PRINTED NAME AND SIGNATURE Series

Fee O.R. No.

( state basis of your claim )

IMPORTANT: IF APPLICANT IS UNABLE TO APPLY IN PERSON THIS FORM SHALL BE NOTARIZED

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FOREIGN SERVICE OF THE PHILIPPINES PHILIPPINE CONSULATE GENERAL CHICAGO, IL U.S.A.

MEDICAL EXAMINATION OF VISA APPLICANT

1REVISED 23 JANUARY 2008 (USA)

122 S. MICHIGAN AVE., SUITE 1600, CHICAGO, IL 60603 Tel. no. (312) 583-0621 Fax no. (312) 583-0647 website: www.chicagopcg.com PLEASE TYPE OR PRINT ANSWERS LEGIBLY IN THE SPACES PROVIDED (IF NOT APPLICABLE WRITE (N/A)

CLASS A

APPLICANT'S PHOTOGRAPH 2 in. x 2 in.

PLACE

AGE

DATE

SEX

MALE FEMALE

CITIZENSHIP CITY

NAME

1. Picture taken within the past 6 months 2. Front View

3. Without eyeglasses

4. Name and Signature on front of photograph

Staple or paste photo here COUNTRY

I CERTIFY THAT ON THE ABOVE DATE I EXAMINED

And that under Philippine Immigration Regulations the applicant should be classified as follows:

(encircle the appropriate class)

Chancroid, Gonorrhea, Granulome, Inguinale, Leprosy (Infectious), Lymphogranuluma Venerum, Syphilis (Infectious Stage), Tuberculosis (Active), and AIDS

Mental Retardation (mental deficiency), Insanity, Antisocial Personality, Mental Defects, Epilepsy, Sexual Deviation, Narcotic Drug Addiction, Chronic Alcoholism

DANGEROUS CONTAGIOUS DISEASES

SERIOUS MENTAL DISORDERS

CLASS B

Person having physical defects, disease or disability serious in degree or permanent in nature that will impair his or her ability to earn a living as to make them likely to be a public charge

IF NOT CLASS A

CLASS C

MINOR CONDITIONS

1. Pertinent medical history:

2. Significant physical examination:

3. Chest X-ray report: (For ages 11 yrs. and above) - Present X-ray film (14 x 17 inches) 4. Laboratory Examination : (Attach laboratory reports) A: Blood serolory: (Ages 15 years and above) B: Urine: (Ages 1 year and above)

C: Stool: (Ages 1 year and above) D: Other examination(s) if necessary:

5. Not physically and mentally defective or diseased

MEDICAL CONDITIONS

Examining Physician (Print Full Name)

Address and Telephone Number(s)

Signature of Examining Physician

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A. NON-QUOTA VISA FOR THE WIFE OR HUSBAND OF A FILIPINO CITIZEN

1. Valid U.S. passport

2. Four (4) passport photographs

3. F.A. Form No. 3 to be accomplished in duplicate

4. F.A. Form No. 11 (Medical form) to be accomplished in duplicate.

5. Original marriage certificate and two (2) photocopies thereof

6. Philippine passport or birth certificate of spouse indicating Philippine citizenship and two (2) photocopies thereof

7. Police Clearance Certificate from place of residence of applicant (original and one photocopy)/ or Discharge papers if recently separated from the U.S. Armed Forces and two (2) photocopies thereof

8. Evidence of financial support, such as bank statement, affidavit of support executed by relatives, or statement of monthly pension. If recently discharged from the U.S. Armed Forces, a statement of the amount of retirement pay each month should be submitted and two (2) photocopies thereof

9. Notarized Letter of Petition signed by Filipino spouse.

B. NON-QUOTA VISA FOR UNMARRIED CHILD UNDER TWENTY-ONE (21) YEARS OF A FILIPINO CITIZEN

4. F.A. Form No. 11 (Medical form) to be accomplished in duplicate 5. Original birth certificate of the child and two (2) photocopies thereof

6. Philippine passport, birth certificate or naturalization papers of parent/s and two (2) photocopies thereof 7. Evidence of financial support, such as bank statement or affidavit of support executed by parent/s and two (2) photocopies thereof

8. Police clearance and two (2) photocopies thereof (for applicants eighteen (18) years of age and over)

C. NON-QUOTA VISA FOR FORMER CITIZENS OF THE PHILIPPINES WHO HAVE BEEN NATURALIZED IN A FOREIGN COUNTRY AND WHO ARE RETURNING TO THE PHILIPPINES FOR PERMANENT RESIDENCE 1. Valid U.S. passport

4. F.A. Form No. 11 (Medical form) to be accomplished in duplicate

5. Philippine passport, birth, baptismal certificate or naturalization papers and two (2) photocopies thereof 6. Evidence of financial support, such as bank statement, affidavit of support executed by relatives, or statement of monthly pension and two (2) photocopies thereof

7. Police clearance and two (2) photocopies

D. NON-QUOTA VISA FOR A CHILD OF ALIEN PARENTS PREVIOUSLY ADMITTED INTO THE PHILIPPINES FOR PERMANENT RESIDENCE IF BORN DURING THE TEMPORARY VISIT ABROAD OF MOTHER

4. F.A. Form No. 11 (Medical form) to be accomplished in duplicate 5. Proof of parent’s Permanent residence in the Philippines 6. Original birth certificate and two (2) photocopies thereof

ADDITIONAL REQUIREMENTS TO BE SUBMITTED BY ALL APPLICANTS

1. Visa fee of US$150.00 in cash, bank draft or money order payable to the Philippine Consulate General.

No personal check can be accepted pursuant to Philippine regulations.

2. Chest X-ray negative (film) or in CD, and medical results must accompany the medical certificate form

3. If applicant wishes the passport and documents to be mailed by the Consulate, applicant should enclose a self-addressed stamped priority/certified/express mail envelope or large pre-paid

FEDEX box or the amount of $30.00 for Express mail will be collected to cover mailing expenses.

METERED STAMPS WILL NOT BE ACCEPTED.

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__________________

Date

Hon. Leo M. Herrera-Lim Consul General

Philippine Consulate

122 S. Michigan Ave., Suite 1600 Chicago, IL 60603

Dear Sir:

I, __________________________________, Filipino citizen, of legal age, married to ___________________________________ with residence and postal address at

_________________________________________________, after having duly sworn to in accordance with law deposes and say:

1. That I am filing this petition for my husband/wife/minor children (below 18 yrs. old).

2. That my husband/wife is ______________________________, currently employed as/retired ______________________________ and my children are:

_______________________________, age ______________

3. That we were married in ____________________________ on

___________________________. Attached is my NSO-certified marriage certificate/

Report of Marriage issued at ______________________________.

4. That I am petitioning my husband/wife/children to live with me permanent in the Philippines where you intend to live.

5. That we have sufficient financial capacity to reside in the Philippines, and will not become a burden to the Philippine government. Attached are documents supporting these claims.

Very truly yours,

_________________________

Signature of Petitioner

SUBSCRIBED AND SWORN TO before me this __________ day of _________________ at _________________________________.

__________________________

Notary Public