FOREIGN SERVICE OF THE PHILIPPINES PHILIPPINE CONSULATE GENERAL CHICAGO, IL U.S.A. FA FORM NO. 3 REVISED 23 JANUARY 2008 (USA) APPLICATION FOR IMMIGRANT VISA 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) 1. NAME AS WRITTEN IN PASSPORT 2. LAST NAME (surname or family name) APPLICANT'S PHOTOGRAPH 2 in. x 2 in. 3. FIRST NAME (all given names) 4. MIDDLE NAME 5. SEX MALE FEMALE 6. CITIZENSHIP 1. Picture taken within the past 6 months 2. Front View 3. Without eyeglasses 4. Name and Signature on front of photograph 7. DATE OF BIRTH (dd/mm/yyyy) 10. IF MARRIED, NAME AND ADDRESS OF SPOUSE 8. PLACE OF BIRTH (city, state or province, country) 9. CIVIL STATUS SINGLE MARRIED WIDOWED DIVORCED SEPARATED Staple or paste photo here FOR OFFICAL USE ONLY IMMIGRANT VISA NO. VISA SHEET NO. 11a. TRAVEL DOCUMENT TYPE 11b. PASSPORT / TRAVEL DOCUMENT NUMBER PASSPORT TRAVEL DOCUMENT 11c. PLACE OF ISSUE (city, state or province,country) DATE OF ISSUE 11d. DATE OF ISSUE (dd/mm/yyyy) 11e. DATE OF EXPIRY (dd/mm/yyyy) DATE OF EXPIRY 11f. VISA REQUESTED NON-QUOTA IMMIGRANT 13. INTENDED PORT OF ENTRY 12. SUPPORTING DOCUMENTS QUOTA IMMIGRANT 14. EXPECTED DATE OF ARRIVAL IN THE PHILIPPINES IMMIGRANT VISA CLASSIFICATION Quota Immigrant Quota No. 15. HOME ADDRESSES FOR THE PAST 5 YEARS* (include apartment number, street, city, state or province, postal zone and country) ADDRESS INCLUSIVE DATES Non-Quota Immigrant under Section of the Philippine Immigration Act of 1940 as amended. VISA ISSUED TO CITIZENSHIP 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 18b. Since BEARER'S TRAVEL DOCUMENT Type No. Date of Isssue Date of Expiry Issuing Authority VISA APPROVED/DENIED BY 22. REFERENCES AND/OR IMMEDIATE RELATIVES IN THE PHILIPPINES NAME ADDRESS RELATIONSHIP SERVICE NO. FEE O.R. NUMBER 23. DATE OF APPLICATION 24. SIGNATURE OF APPLICANT RECEIVER PROCESSOR CASHIER SCRIPTER LOL ENCODER Page1-2
25. OCCUPATION 26. NAME AND ADDRESS OF EMPLOYER IN THE PHILIPPINES 27. ADDRESS IN THE PHILIPPINES WHERE THE APPLICANT INTENDS TO SETTLE (include apartment number, street, city, state or province, postal zone ) 28. ON WHAT BASIS DO YOU CLAIM TO BE A PREFERENCE QUOTA IMMIGRANT NON-QUOTA IMMIGRANT? ( state basis of your claim ) 29. HAVE YOU EVER BEEN CONVICTED OF ANY CRIME? YES ( specify crime and date of conviction ) NO 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 31. HAVE YOU EVER BEEN INSTITUTIONALIZED FOR ANY MENTAL DISORDER? YES ( state particulars and date of institutionalization) NO 32. HOW WILL YOU SUBMIT THIS APPLICATION? PERSONAL MAIL / COURIER TRAVEL AGENCY / REPRESENTATIVE Name of Travel Agency / Authorized Representative 33. DO YOU HAVE ANY PHYSICAL DEFECT OR CONTAGIOUS DISEASE? YES ( state defect or disease and other particulars) NO IMPORTANT: 34. 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. IF APPLICANT IS UNABLE TO APPLY IN PERSON THIS FORM SHALL BE NOTARIZED I solemnly swear under penalty of law that the foregoing statements are true and correct and the attached supporting documents are authentic. Signature of Applicant Over Printed Name SUBSCRIBED AND SWORN to before me this day of,cy, at. Notary Public Consul of the Republic of the Philippines FOR OFFICIAL USE ONLY. REMARKS Doc. No. Series Service No. O.R. No. Fee TRAVEL DOCUMENT RELEASED TO PRINTED NAME AND SIGNATURE DATE RECEIVED / MAILED MAIL/COURIER TRACKING NO. Page 2-2
FOREIGN SERVICE OF THE PHILIPPINES PHILIPPINE CONSULATE GENERAL CHICAGO, IL U.S.A. MEDICAL EXAMINATION OF VISA APPLICANT PLEASE TYPE OR PRINT ANSWERS LEGIBLY IN THE SPACES PROVIDED (IF NOT APPLICABLE WRITE (N/A) 1REVISED 23 JANUARY 2008 (USA) PLACE DATE 122 S. MICHIGAN AVE., SUITE 1600, CHICAGO, IL 60603 Tel. no. (312) 583-0621 Fax no. (312) 583-0647 website: www.chicagopcg.com CITY NAME COUNTRY I CERTIFY THAT ON THE ABOVE DATE I EXAMINED APPLICANT'S PHOTOGRAPH 2 in. x 2 in. 1. Picture taken within the past 6 months 2. Front View 3. Without eyeglasses 4. Name and Signature on front of photograph AGE SEX MALE FEMALE CITIZENSHIP Staple or paste photo here And that under Philippine Immigration Regulations the applicant should be classified as follows: (encircle the appropriate class) DANGEROUS CONTAGIOUS DISEASES Chancroid, Gonorrhea, Granulome, Inguinale, Leprosy (Infectious), Lymphogranuluma Venerum, Syphilis (Infectious Stage), Tuberculosis (Active), and AIDS CLASS A SERIOUS MENTAL DISORDERS Mental Retardation (mental deficiency), Insanity, Antisocial Personality, Mental Defects, Epilepsy, Sexual Deviation, Narcotic Drug Addiction, Chronic Alcoholism CLASS B CLASS C IF NOT CLASS A 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 MINOR CONDITIONS MEDICAL 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 Examining Physician (Print Full Name) Address and Telephone Number(s) Signature of Examining Physician
REQUIREMENTS FOR PERMANENT RESIDENT VISA A. NON-QUOTA VISA FOR THE WIFE OR HUSBAND OF A FILIPINO CITIZEN. 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 ischarge D 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 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 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 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.
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: 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