APPLICATION FOR RETENTION / RE-ACQUISITION OF PHILIPPINE CITIZENSHIP
FOREIGN SERVICE OF THE PHILIPPINES
PHILIPPINE CONSULATE GENERAL
CHICAGO, IL U.S.A.
122 S. MICHIGAN AVE., SUITE 1600, CHICAGO, IL 60603
website: www.chicagopcg.com
Tel. no. (312) 583-0621 Fax no. (312) 583-0647
Revised 23 JANUARY 2008 (USA)
1a. LAST NAME (surname or family name)
1b. FIRST NAME (given names)
4. PLACE OF BIRTH (town or city, province or state , country)
5. SEX
10a. NAME OF APPLICANT'S FATHER (last name, first name, full middle name)
MALE
FEMALE
12. HOW PHILIPPINE CITIZENSHIP WAS INITIALLY ACQUIRED
ELECTIONBIRTH MARRIAGE NATURALIZATION
OTHERS (specify)
MONTH (write whole word) YEAR
9a. NAME OF SPOUSE (last name, first name, full middle name)
10b. FATHER'S CITIZENSHIP AT THE TIME OF APPLICANT'S BIRTH
11a. NAME OF APPLICANT'S MOTHER (last name, first name, full middle name) 11b. MOTHER'S CITIZENSHIP AT THE TIME OF APPLICANT'S BIRTH
13a. APPLICANT'S CURRENT FOREIGN CITIZENSHIPS (specify all) 13b. MODE OF ACQUISITION OF FOREIGN CITIZENSHIPS (specify all)
14a. DATE OF ACQUISITION OF FOREIGN CITIZENSHIPS (day / month / year) 14b. NATURALIZATION CERTIFICATE NUMBERS
15a. FOREIGN PASSPORT NO. / VALID FOREIGN GOV'T ISSUED ID NO. 15b. DATE AND PLACE OF ISSUANCE OF ID (day/ month/ year)
1c. MIDDLE NAME
(mother's maiden surname)
6. CIVIL STATUS
PETITION NO.
DATE FILED
.
FRONT VIEW FRONT VIEW
DAY
7. HEIGHT (m) 8. WEIGHT (kg)
2. ARE YOU USING A
DIFFERENT NAME?
2d. SUPPORTING DOCUMENTS FOR CHANGE OF NAME
ORDER OF
APPROVAL/DENIAL NO.
DATE OF
APPROVAL/DENIAL
. .
16. SUPPORTING DOCUMENTS SUBMITTED
Birth Certificate
Others (specify) ________________________
Report of Birth Baptismal Certificate
Affidavit of _____ Disinterested Person(s)
Old Philippine Passport
Naturalization Certificate
Marriage Certificate
18. ADDRESS IN U.S. OR COUNTRY OF RESIDENCE (house no., street, town or city, state, country, postal zone)
2a. LAST NAME (surname or family name)
2b. FIRST NAME (given names)
CONTINUE ON REVERSE SIDE
22. PRESENT OCCUPATION19. HOME TELEPHONE NO. 20. E-MAIL ADDRESS
24. APPLICANT'S SIGNATURE23. WORK ADDRESS/WORK NUMBER (office name, building no., street, town or city, state, country, postal zone)
21. MOBILE NUMBER
YES
NO
17. PHILIPPINE PERMANENT ADDRESS (house no., street, town or city, state, country, postal zone)
page 1 of 2
plain white background taken
within last six (6) months, without
eyeglasses,clearly showing the
full front view of the face
2"X2 " Colo red Photogra ph
plain white background taken
within last six (6) months, without
eyeglasses,clearly showing the
full front view of the face
2"X2 " Colored Photograph
I
F YES, INDICATE NAME
CURRENTLY USED
.1. N1.
2c. MIDDLE NAME
.
9b. CITIZENSHIP OF SPOUSE AT THE TIME OF APPLICATION
3. DATE OF BIRTH
INSTRUCTION
The original and one (1) photocopy
of the Application and the
Petition for Reacquisition /
Retention of Philippine Citizenship
should be submitted together with
two (2) photocopies
of all supporting documents.
1. NAME AS WRITTEN ON
PHILIPPINE BIRTH
CERTIFICATE OR
REPORT OF BIRTH
Distinguishing Marks on face: