APPLICATION FOR RETENTION / RE-ACQUISITION OF PHILIPPINE CITIZENSHIP
FOREIGN SERVICE OF THE PHILIPPINES
____________________________________
____________________________________
____________________________________
____________________________________
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/FAX NO.
24. APPLICANT'S SIGNATURE23. WORK ADDRESS (office name, building no., street, town or city, state, country, postal zone)
21. WORK TELEPHONE 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" Colored Photograph
plain white background taken
within last six (6) months, without
eyeglasses,clearly showing the
full front view of the face
2"X2 " Colored Photograph
IF 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 four (4) photo
copies of the Application and the
Petition for Reacquisition /
Retention of Philippine Citizenship
should be submitted together with
the original and four (4) photo
copies of all supporting documents.
1. NAME AS WRITTEN ON
PHILIPPINE BIRTH
CERTIFICATE OR
REPORT OF BIRTH
____________________________________
PHILIPPINE CONSULATE GENERAL
LOS ANGELES, CALIFORNIA, USA
Submit this Application Form
along with the supporting
documents and three (3)
2x2 colored plain white
background taken within
the last six (6) months, without
eyeglasses, clearly showing
the full front view of the face
NSO/PSA BIRTH CERTIFICATE
OLD PHILIPPINE PASSPORT
LCR BIRTH CERTIFICATE
NATURALIZATION CERTIFICATE
NSO/PSA/"CENSUS"
BIRTH CERTIFICATE
OLD PHILIPPINE PASSPORT
REPORT OF BIRTH
FROM CONSULATE/EMBASSY
NATURALIZATION CERTIFICATE
FOREIGN PASSPORT
CERTIFICATE OF LIVE BIRTH
FROM PHILIPPINE LCR
PHILIPPINE MARRIAGE CERTIFICATE
REPORT OF BIRTH FROM A PH
CONSULATE/EMBASSY
FOREIGN NATURALIZATION CERT
CELLPHONE NUMBER
FEES:
[ ] PRINCIPAL $ 50.00
[ ] DERIVATIVE
____ X $25.00 = $ ______
[ ] AFFIDAVIT
OF EXPLANATION $ 25.00
TOTAL: $ ________
INSTRUCTION
This application form should
be accomplished completely
and submitted together with
the original supporting
documents, one (01)
photocopied set of the original
documents and three (03) 2x2
colored photos described in the
next frame.
PASTE HERE one (1) of the (3)
2x2 colored photos with plain
white background taken
within the last SIX (6) months,
without eyeglasses or
contact lenses, clearly
showing the full front view of
the face
(Revised July 2019 PCGLA)
